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Left Underlapping Third Toe in a Patient who Underwent Ventricular Assist Device Implantation: A Case Report and Literature Review

Posted on December 1, 2012 | Comments Off on Left Underlapping Third Toe in a Patient who Underwent Ventricular Assist Device Implantation: A Case Report and Literature Review

by Massimiliano Polastri, MSc, PT1 , Walter Trani, PT1, Mariano Cefarelli, MD2, Sofia Martìn-Suàrez, MD2

The Foot and Ankle Online Journal 5 (12): 2

This case report describes a rare abnormality of the forefoot in an adult who underwent implantation of a ventricular assist device. Toe deformities are not necessarily related to pain and/or functional foot limitations. An underlapping toe is a rarely, described disorder. Ventricular assist devices (VAD) are comprised of a set of tools that allows the system to substitute for the pump function of the heart in eligible patients. A 60-year-old Caucasian man affected by ischemic dilated cardiomyopathy underwent ventricular assist device implantation as a bridge to transplantation. The third toe abnormality reported here did not influence the ventricular assist device implantation or postoperative recovery in terms of exercising. An underlapping third toe can coexist in the presence of debilitating illness without causing particular physical difficulties.

Key words: Blood circulation, Forefoot, Gait, Heart transplantation, Quality of life, Rehabilitation, Toes abnormalities.

Accepted: November, 2012
Published: December, 2012

ISSN 1941-6806
doi: 10.3827/faoj.2012.0512.0002

Toe deformities are not necessarily related to pain and/or functional foot limitations. [1] Rare abnormalities such as overlapping toes are a condition for which there is no possibility for spontaneous improvement. [2]

In contrast, an underlapping toe is a rare and little-described disorder. Friend found that the fourth and fifth toes are the most involved in an underlapping toe abnormality even if the second or third toes are also affected. The combination of congenitally elongated toes and an acquired adductovarus is the major mechanism that produces this deformity. [3] Ventricular assist devices (VAD) are comprised of a set of tools that allows the system to substitute for the pump function of the heart in eligible patients.

The main body of the device includes a miniaturized titanium pump. The power cord of the device used in the case described here was connected to a titanium base fixed to the skull (parietotemporal). [4]

The system is powered by lithium and lead batteries—which have different durations—and is transported in a bag in a horizontal position so as not to cover the microphone alarm. Left ventricular assist devices (LVAD) are an effective strategy to prolong survival and improve quality of life. [5] The Interagency Registry for Mechanically Assisted Circulatory Support has been created to collect information about patients, devices, and outcomes, including adverse events.  [6] The main purpose of this report is to describe a rare abnormality of the forefoot in an adult who underwent implantation of a VAD.

Case Report

A 60 year-old Caucasian man affected by ischemic dilated cardiomyopathy underwent LVAD implantation (Jarvik Heart®, New York, NY, USA) as a bridge to transplantation. He had diabetes, dyslipidemia and was an ex-smoker.

He did not undergo myocardial revascularization after two episodes of acute myocardial infarction, and 8 years ago he was implanted with a single-chamber implantable cardioverter. The patient underwent pre-transplant screening for nearly 2 years. It was decided to apply a temporary LVAD due to his low cardiac ventricular function (ejection fraction, 22%) and significant pulmonary hypertension. This device has a compact axial flow impeller pump with an outflow Dacron graft for anastomosis to the descending thoracic aorta. The pump was inserted through a sewing cuff into the apex of the left ventricle. The adult model measured 2.5 cm in diameter by 5.5 cm in length. Its weight was 85 g with a displacement volume of 25 mL. The postoperative course was free of complications. Bilateral hallux valgus and an underlapping third toe on the left side were noted by observation of the patient in a standing position. (Fig.1) Deviation in the valgus of the right big toe was more evident, as was pronation of the first metatarsophalangeal joint (this condition probably avoided the hammer toe on the same side). The left foot was characterized by hammer toes (Fig. 2), and the congenital underlapping third toe was attached to the first toe through the distal portion of both toes. (Fig. 3)

PolOLtoeFig1

Figure 1 Standing position. Right side: hallux valgus, hammertoes second to fifth. Left side: hammertoes first to fifth, hallux valgus, underlapping third toe.

PolOLtoeFig2

Figure 2 Dorsal view of the left side: underlapping third toe.

PolOLtoeFig3

Figure 3 Plantar view of the left side: the third toe is medially deviated (two red arrows) and attached to the first (four red arrows).

The patient had no difficulties ambulating and was free from pain. Thus, postoperative rehabilitation was centered on recovery of motor activity and reconditioning after the VAD implantation. The first line of the rehabilitative treatment in the sub-intensive setting was focused on encouraging the patient to perform exercises (even in a group) such as cycling, climbing stairs, and walking (even outside the pavilion); the patient’s performance of exercises was monitored. Furthermore, all motor activities were performed in association with respiratory exercises, such as deep breathing and incentive spirometry. The patient provided written informed consent for this study.

Discussion

The absence of both foot pain and functional limitations at the initial examination was unexpected, but allowed the patient to adhere to the postoperative rehabilitation program, with excellent results. Augustine and Jacobs described hammertoes as the most common deformities of the foot. [7] Abnormalities of the forefoot, particularly in children are described in the literature. Smith, et al., found that an underlapping toe was common in a pediatric population of 44 newborns and proposed a simple algorithm for treatment. [8] In the mid-1960s, Greenberg discussed the possibility of resolving underlapping and contracted toes by plantar digital tenotomy, in the absence of shortening of the dorsal tissue and subluxation of the metatarsophalangeal. [9]

Similarly, Korn proposed a surgical approach for correction of a painful underlapping fifth toe and reported excellent outcomes of surgery. [10] Fattirolli, et al., discussed the importance of a customized rehabilitation program in patients undergoing VAD to enhance function and the quality of life. [4] A multidisciplinary approach is the ideal solution for long-term care during postoperative recovery. [11] Furthermore, the benefits of exercise training were reported by Bellotto, et al., who discussed the postoperative course of a patient with an implanted artificial heart. [12] Polastri investigated the role of postoperative rehabilitation after hallux valgus surgery, and surmised that a rehabilitative intervention is required to encourage both plantar pressure on the first ray and joint mobility. [13] If these are the objectives of hallux valgus surgery, what is advisable in terms of exercise in a case such as that we report here in which the deformities were not corrected? The answer to this question must consider the rationale of the treatment according to both the condition of the patients and their quality-of-life expectations. In fact, the patient described here was admitted so that his cardiac function issues could be addressed; the feet abnormalities (hallux valgus, hammer toes, and underlapping third toe) were an occasional finding of secondary importance considering his overall condition. The postoperative rehabilitation pathway, particularly in specialized settings, must be appropriate and centered on the patient’s needs with due consideration of their priorities. In this regard, the third toe abnormality reported here did not influence the VAD implantation or postoperative recovery in terms of exercising. The main limitation of this case report is the lack of quantification of the foot-joint deformities by means of range-of-motion measurements. However, the aim of this case study was to describe an unusual abnormality that does not require deep investigation. Furthermore, our findings should not be extended to a larger population. Nevertheless, this is to our knowledge the first report of feet deformities in a patient implanted with a VAD. In summary, an underlapping third toe can coexist in the presence of debilitating illness without causing particular physical difficulties.

References

1. Badlissi F, Dunn JE, Link CL, Keysor JJ, McKinlay JB, Felson DT. Foot musculoskeletal disorders, pain and foot-related functional limitation in older person. J Am Geriatr Soc 2005 53: 1029-1033. [PubMed]
2. Hulman S. Simple operation for the overlapping fifth toe. Br Med J 1954 2: 1506-1507. [PubMed]
3. Friend G. Correction of elongated underlapping lesser toes by middle phalangectomy and skin plasty. J Foot Surg 1984 23: 470-476. [PubMed]
4. Fattirolli F, Bonacchi M, Burgisser C, Cellai T, Francini S, Valente S, Sani G, F. Cardiac rehabilitation of patients with left ventricular assist device as “destination therapy”. Monaldi Arch Chest Dis 2009 72: 190-199. [PubMed]
5. Maciver J, Ross HJ. Quality of life and left ventricular assist device support. Circulation 2012 126: 866-874. [PubMed]
6. Rector TS, Taylor BC, Greer N, Rutks I, Wilt TJ. Use of left ventricular assist device as destination therapy in end-stage congestive heart failure: a systematic review. 2012, Washington (DC), Department of Veterans Affairs. URL: http://www.ncbi.nlm.nih.gov/books/NBK99059/pdf/TOC.pdf. [PDF] (accessed 18 August 2012). [Website]
7. Augustine DF, Jacobs JF.V Restoration of toe function with minimal traumatic procedures including advanced diaphysectomy. Clin Podiatry 1985 2: 457-470. [PubMed]
8. Smith WG, Seki J, Smith RW. Prospective study of a noninvasive treatment for two common congenital toe abnormalities (curly/varus/under lapping toes and overlapping toes). Pediatr Child Health 2007 12: 755-759. [PubMed]
9. Greenberg HH. Plantar digital tenotomy for underlapping and contracted toes. J Am Podiatry Assoc 1966 56: 65-66. [PubMed]
10. Korn SH. The lazy S approach for correction of painful underlapping fifth digit. J Am Podiatry Assoc 1980 70: 30-33. [PubMed]
11. Pistono M, Corrà U, Gnemmi M, Imparato A, Caruso R, Balestroni G, Tarro Genta F, Angelino E, Giannuzzi P. Cardiovascular prevention and rehabilitation for patients with ventricular assist device from exercise therapy to long-term therapy. Part II: long-term therapy. Monaldi Arch Chest Dis 2011 76: 136-145. [PubMed]
12. Bellotto F, Compostella L, Agostoni P, Torregrossa G, Setzu T, Gambino A, Russo N, Feltrin G, Tarzia V, Gerosa G. Peripheral adaptation mechanisms in physical training and cardiac rehabilitation: the case of a patient supported by a CardioWest total artificial heart. J Card Fall 2011 17(8): 670-675. [PubMed]
13. Polastri M. Postoperative rehabilitation after hallux valgus surgery: a literature review. FAOJ 2011 4(6): 4. [Website]

Address correspondence to: Massimiliano Polastri, Physical Medicine and Rehabilitation, Bologna, University Hospital Authority, Sant’Orsola-Malpighi Polyclinic, Via G. Massarenti, 9. 40138 –Bologna, Italy.

1  Physical Medicine and Rehabilitation, Bologna University Hospital Authority, Sant’ Orsola-Malpighi Polyclinic, Bologna, Italy.
2  Cardiac Surgery Department, Sant’ Orsola-Malpighi Polyclinic, Bologna University, Bologna, Italy.

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Subtalar Arthroereisis with Endorthesis in Adult-acquired Flatfoot: Classification of the Postoperative Rehabilitation Phases

Posted on April 1, 2012 | Comments Off on Subtalar Arthroereisis with Endorthesis in Adult-acquired Flatfoot: Classification of the Postoperative Rehabilitation Phases

by Massimiliano Polastri, MSc, PT1, Alessandro Graziani, MSc, PT1, Stefano Cantagalli, MD2

The Foot and Ankle Online Journal 5 (4): 1

Flatfoot is a biomechanical condition in which the medial longitudinal arch collapses, causing flattening of the foot towards the ground. In adult-acquired flatfoot, the subtalar joint has a greater range of motion than a normal foot, and multiple factors can cause the onset of this condition. Subtalar arthroereisis with endorthesis is a surgical procedure by which an implant is positioned in the sinus tarsi depression in order to limit the excessive pronation of the subtalar joint. Subtalar arthroereisis is often associated with adjunctive procedures. A period of three weeks of non-weight bearing is recommended after surgery and additional protection is achieved as the load is increased. In order to be able to discuss the postoperative course, it is useful to be able to classify it. Basically, the classification proposed in this paper is a practical/theoretical instrument which seeks to contribute to a better understanding and achievement of the aims and outcome desired at each stage described. Postoperative rehabilitation must be oriented to both protect the surgical site and to enhance foot mobility. We have proposed a classification of the rehabilitative pathway after subtalar arthroereisis with endorthesis based on our experience, also considering the related literature. Furthermore, we provide a synthetic description of the surgery, and the rehabilitation techniques are discussed. The ultimate goal of the rehabilitation project is centered on obtaining the physical condition closest to that required for the daily activity of the healthy population with the aim of returning to full recovery after surgery. To this end, a certain degree of multiprofessional cooperation is always recommended in order to ensure patient safety and obtain the best results.

Key words: Flatfoot, Gait, Prostheses and Implants, Rehabilitation, Subtalar Joint, Surgical Cast, Weight-Bearing.

Accepted: March, 2012
Published: April, 2012

ISSN 1941-6806
doi: 10.3827/faoj.2012.0504.0001

Flatfoot (FF) is a biomechanical condition in which the medial longitudinal arch collapses causing flattening of the foot towards the ground. The onset of this disorder may occur at different ages from the first years of life up to adulthood.

In adult-acquired flatfoot (AAF), the subtalar joint (STJ) has a greater range of motion than a normal foot, and multiple factors can cause the onset of this condition.[1] The STJ is a diarthrosis (trochoid) which connects, in two different locations (separated by the sinus tarsi depression), the posterior-inferior surface of the talus with the superior face of calcaneus and the anterior-inferior part of the talus with the anterior-superior surface of the calcaneus. The articular activities possible at this level are adduction and abduction of the rearfoot, associated with the supination and pronation of the foot, respectively. The realization of these complex movements is facilitated by Chopart’s joint (midtarsal).[2] Arthroereisis is a surgical procedure which limits the amount of motion possible in a joint which has become excessively mobile.[3] In subtalar arthroereisis (SA) with endorthesis, an implant is positioned in the sinus tarsi depression in order to limit the excessive pronation of the STJ, which is typically present in AAF.[4-6] Although it has proven to be an effective surgical technique, certain complications are described in the literature.[7-10] Essentially, in the past, major interest was focused on pediatric patients.[11,12] More recently, Evans (2008) has defined a therapeutic algorithm for rehabilitation treatment in children.[13] Originally, the insert of an expandable orthosis was used for the treatment of pediatric flat foot.[14-16] Characteristics of the implants are discussed in the literature.[17] Evans and Rome (2011), have found that there is limited evidence of the efficacy of non-surgical intervention in children with flexible flat feet. In their research, these authors have also provided a wide and complete overview of the surgical approaches available, including arthroereisis.[18] As introduced above, pronation is one of the movements (together with supination) possible at the subtalar level; one must be aware of this because valgus of the rearfoot characterizes AAF. Postan et al. (2011) have discussed the association of the anatomical variations of the spring ligament and sustentaculum tali with the risk of developing AAF.[19] Chang and Lee (2007) have provided a careful description of the kinematics, the surgical treatment, and the indications and contraindications as well as the postoperative management, and have described one condition which causes flexible AAF namely: the posterior tibial tendon dysfunction.

For the correction of AAF, adjunctive procedures are often carried out using SA. A period of three to four weeks of non-weight bearing in a cast is recommended after surgery and additional protection is achieved with the use of a walker for more three weeks as the load is increased.[20] The main purpose of this study was to classify the rehabilitation phases after surgical correction of AAF by means of SA with endorthesis. The literature was reviewed to identify studies which have investigated postoperative rehabilitation after SA. To our knowledge, no previous papers have been published on this matter.

Surgery at a glance

We herein describe the procedure of subtalar arthroereisis with endorthesis in association with additional procedures on soft tissues for the treatment of painful and flexible AAF.[5,20] Subtalar arthroereisis locks the sliding between the talus and the calcaneus, restoring their positions; an implant (ProStop®, Arthrex Inc., Naples, FL 34108, US) is inserted within the sinus tarsi determining the reduction of the pronation of the STJ acting as a self-locking wedge, according to Vogler’s classification.[21] This system is composed of titanium cannulated screws, threaded and conical in shape, of different sizes (7 to 12 mm) and lengths (12 to 16 mm) so that they can be precisely adapted to the tarsal canal. The anesthesia is generally spinal and specific for the limb operated on. It is carried out by injecting anesthetic into the subarachnoid space with a 25 Gauge needle by means of a injection of the dura mater and of the arachnoid in the lumbar spaces below L2. To this end, the patient is positioned in a sitting position or in lateral decubitus, and the procedure is performed aseptically. Before placing the patient on the operating table, one must wait approximately 5-10 minutes to evaluate the level of the anesthesia. The surgical technique is performed with the patient in a supine position on the operating table with a tourniquet at the root of the thigh root after inserting the limb into an Esmarch bandage. The tourniquet is applied to induce lower limb ischemia so as to create a bloodless field in order to better identify the vascular structures, nerves and tendons.

An incision of approximately two cm on the lateral portion of the sinus tarsi is made, allowing the insertion of a guide wire between the two beams of the talar-calcaneal ligament and the interosseus ligament; this facilitates the introduction of a size tester. Under fluoroscopy, the correct implant dimension is determined and the surgeon can proceed with the insertion of the screw using a screwdriver until, the screw itself, is level with the outer edge of side wall of the talus neck. The guide wire is removed and a stitch is applied. At this point, the tension of the triceps tendon is evaluated and, if necessary, a Hoke’s percutaneous tenotomy is performed to achieve the appropriate dorsal flexion of the ankle joint.[22] Subsequently, to correct the talus protrusion, an additional internal procedure of tensioning of the posterior tibial tendon is carried out:[23,24] an incision of approximately four cm is made on the navicular tuberosity, the tendon is detached from the navicular tubercle maintaining the plantar extension of the fibers, and the periosteum is dissected. The prominence of the navicular is then tangentially excised and, if present, accessory bone is removed; tenolysis, repair and tensioning of the posterior tibial tendon are performed at this point. The surgery, including the additional procedures as described above, requires approximately 60 minutes.

Rehabilitation phases

Antithrombotic prophylaxis is managed at home with low molecular weight heparin for thirty days after surgery. During the postoperative course, the patient must use a walker for thirty-five days and walk without weight bearing for the first three weeks. Between days twenty-one and thirty-five, the load is progressively increased. In order to be able to discuss the postoperative course after SA with endorthesis, it is useful to be able to classify it. Basically, the classification proposed in this study is a practical/theoretical instrument which may help professionals to better understand and achieve the aims and outcome desired at each stage described. Each phase must be carefully evaluated both physically and clinically.

If we think of the STJ as two overlapped cylinders, we immediately realize that, at this level, the maximum range of motion is possible in the transverse plane: the cylinders can thus produce movements of pronation and supination. Conversely, flexion and extension are limited due to the anatomical surfaces (Fig. 1).

Figure 1 Schematic representation: sinus tarsi is an anatomical space present between the talus (top) and the calcaneus (bottom). Due to the anatomical surfaces, the two cylinders can roll one upon the other (pronation and supination).

Stage 1 (immobilization and pain)

After surgery, patients are advised not to put weight on the foot and to use a walker in order to protect the surgical site for a period of three weeks. In this initial phase, the patient is likely to be overcautious and have some degree of fear, in carrying out the usual daily activities. Both, pain and infection prevention procedures are similar to those provided in arthroscopic surgery of the ankle.[25] Conversely, patients undergoing ankle arthroscopic excision do not wear a cast after surgery and they are advised to limit the range of motion and to protected the load in the first twenty-four hours postoperatively.[26] On the other hand, in surgical procedures of the ankle more invasive than SA, patients are encouraged to exert weight after surgery.[27]

In patients undergoing SA, if a physiotherapist is involved in stage 1, in order to prevent/manage any complications, he/she must be present as a counselor and must refer every unusual condition (after clinical evaluation) which may compromise the postoperative course. When no red flags (severe pain, heat, inability to walk even with the walker) are present, the rehabilitation activity is limited to observation and advice (sleeping with minimum elevation of the feet putting a pillow under the mattress, walking short differences but often, maintaining proper alignment of the pelvis through the correct use of crutches, noting if there is blood in the dressing, regularly using the walker). Orthopedic procedures are recognized as the most painful because of the need to walk.[28] In stage 1, pain should be low to moderate and no additional treatment is usually required. Otherwise, the patient must be referred to a physician.

Stage 2 (edema, pain and weight-bearing)

When the dressing is removed after 35 days, the physiotherapist must check for the presence of edema. If, in the previous stage, pain control was obtained by means of anti-inflammatory drugs or painkillers, the residual -algic conditions must now be evaluated and eventually treated by referring the patient to a physician.

Permanence of the -algic symptoms represents a complication assuming that, after one month, in almost all cases, pain should be at a minimum. Nevertheless, a certain degree of discomfort is present during or after walking/standing. Furthermore, in this period, which covers the first 35-50 days, the presence or absence of possible algodystrophy must be evaluated. Tenderness, vascular instability, stiffness and swelling, if present, are red flags for this issue. On the other hand, if the foot is not swollen, not hot and not painful, the edema (if present) can be treated through massage, and elevation at night. Thanks to the surgical technique, manual treatment of the sinus tarsi scar is not usually necessary (minimal access); conversely, manual massage is performed to facilitate the disappearance of the scar on soft tissue procedure sites using an elasticizing cream (Rilastil® Laboratori Milano, Istituto Ganassini S.p.A. di Ricerche Biochimiche, 20139 Milano, IT) (Fig. 2). Usually, at the end of stage 2, the patients no longer need a walker and/or crutches. Weight bearing is progressively allowed and the patient can wear sport shoes. Articular mobilization should be pursued at the following levels: talocrural joint and forefoot.

Figure 2 Scar massage on the surgical access of the posterior tibial tendon.

To protect the implanted endorthesis, pronation and supination of the STJ are not required or even encouraged. As described above, this diarthrosis would be comparable to a pair of overlapped cylinders which move around the longitudinal axis of the foot. Why force pronation or supination at this level when, after surgery, they are protected? Conversely, mobilization of the areas peripheral to the surgery are recommended in order to achieve the maximum interest on the part of the patient in recovery. Plantar and dorsal flexion of the ankle and mobilization of the forefoot are carried out with the patient in a supine position with the knee supported in flexion: block the STJ with the proximal hand to avoid pronation or supination at this level during articular recruitment (Figs. 3 and 4). The proprioceptive component is important at this stage and should be composed of several levels, compatible with weight bearing. The manual approach should start with closed kinetic chain exercises stimulating coordinated muscle contraction in the articular segments of the lower limb increasing the capsular-ligament stability of the ankle itself.

Figure 3 The physiotherapist’s proximal hand blocks the STJ to limit eversion and inversion of the foot whereas plantar and dorsal flexion are performed.

Figure 4 Passive movement of the first ray with the STJ blocked by the proximal hand.

In addition to developing muscle strength, these exercises optimize the functional capacity of the individual by encouraging recovery of the physiological activities of the joint operated on. Closed kinetic chain exercises take advantage of the normal joint structure, and the entire proprioceptive system is stimulated. To perform exercises with patient in a supine position, the ankle is placed in a side panel in front of the subject. Making the first movements in an anterior-posterior direction is encouraged to recreate and improve neuromuscular coordination; the same movements are necessary in the lateral direction and then combined across multiple directions, always with the foot in contact with the wall. Once the patient is capable of tolerating an increased load, the physiotherapist can propose the same procedure with the patient first sitting and then standing with the foot resting on the ground. As this stage is focused on proprioception, unstable balance tools should be used in order to enhance both dorsal and plantar flexion.

Stage 3 (mobility and gait)

At approximately 50 days, assuming that pain and edema have been resolved or are in resolution, the patient must be encouraged to increase mobility. Exercises and mobility techniques are continue using an elastic band (Thera-Band®, The Hygenic Corporation, Akron, OH 44310, US) to develop progressive resistance in the various planes of motion (Figs. 5 and 6). The patient should be instructed and encouraged to do these exercises even in the absence of the physiotherapist, the so-called phase of self treatment at home is essential at this point in order to optimize the timing and results.[29] Hupperets, et al., (2009) have found that unsupervised proprioceptive home based training could benefit the general population.[30] Basically, rehabilitation at this stage is still focused on proprioception using unstable balance tools with both unilateral and bilateral weight bearing. The final phase of muscular strengthening is dedicated to all antigravity movements in which the foot is in a challenging biomechanical context. The patient undergoes a series of exercises which are in contrast to the body weight acting together with gravity.

Figure 5 Muscular self-administered strengthening in a supine position (plantar-dorsal flexion) using a Thera-Band®.

Figure 6 In a sitting position, the patient is encouraged to carry out movements in all directions regulating/increasing the elastic resistance with their own hands.

The starting point of these exercises begins with the full load step on the limb which was operated on; key element for ensuring recovery of the physiological gait. More challenging related exercises are represented by walking uphill with a gradual slope (for example treadmill), climbing the stairs one or two steps at a time and then coming down the stairs (to stimulate the eccentric component of the muscle contraction). Both strength and antigravity exercises are recommended to achieve the full recovery and return to the normal activity. In this phase, the patients should be referred to hydrokinesitherapy to maximize results and improve the postoperative outcome. Berger, et al., (2006), comparing the immediate effects of standard physiotherapy and balneotherapy on postural capacity in subjects with lower limb injuries, observed that exercising under water could reinforce proprioceptive input.[31] A good recovery of foot function can be achieved by proposing implementation of walking synergies such as walking backwards on one’s own toes, walking on heels or cross stepping.

The help of a mirror can provide valuable visual feedback in order to correct any altered patterns. One must research transition from normal to faster walking and then to running. The ultimate goal of the rehabilitation project is centered on obtaining the best physical condition closest to the daily activity of the healthy population with the aim of returning to full recovery after surgery.

Stage 4 (return to sports activities)

The last phase of antigravity training is completed with proper exercises such as jumping in place or on a trampoline. A gradual resumption of the sports activity previously carried out is allowed and a radiographic check-up is required to verify the implant positioning.

Conclusions

Despite the fact that SA was initially proposed for pediatric patients, it is being an increasingly used procedure in the adult population. In this paper we have proposed a classification of the rehabilitative pathway after SA based on our experience also considering the related literature. The main limit of our classification is represented by the absence of a sample with which to make statistical comparisons. Nevertheless, we wanted to address the matter when we realized the need for clarifying and classifying a patient’s physical condition after corrective surgery. Again, even with its limits, this overview should help and stimulate further research. After subtalar arthroereisis with endorthesis, postoperative rehabilitation must be oriented both to protect the surgical site and to enhance mobility of the foot. In order to maximize results and contain clinical risk, the physiotherapist must be able to carry out a functional evaluation and, if necessary, refer patients when complications occur. To this end, a certain degree of multiprofessional cooperation is always recommended in order to ensure patient safety and achieve the best results.

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23.  Gould JS. Direct repair of the posterior tibial tendon. Foot Ankle Clin 1997 2: 275-279.
24.  Giannini S, Vannini F, Bevoni R, Romagnoli M, Di Gennaro V. Trattamento chirurgico delle lesioni del tibiale posteriore. In: Progressi in medicina e chirurgia del piede. Bologna: Timeo, 2007 16: 73-87.
25.  Bonasia DE, Phisitkul P, Saltzman CL, Barg A, Amendola A. Arthroscopic resection of talocalcaneal coalitions. Arthroscopy 2011 27: 430-435. [PubMed]
26.  Noguchi H, Ishii Y, Takeda M, Hasegawa A, Monden S, Takagishi K. Arthroscopic excision of posterior ankle bony impingement for early return to the field: short-term results. Foot Ankle Int 2010 31: 398-403. [PubMed]
27.  Talarico LM, Vito GR, Zyryanov SY. Management of displaced intraarticular calcaneal fractures by using external ring fixation, minimally invasive open reduction, and early weight bearing. J Foot Ankle Surg 2004 43: 43-50. [PubMed]
28.  D’Amours RH, Ferrante FM. Postoperative pain management. JOSPT 1996 24: 227-236. [PubMed]
29.  Mikesky AE, Topp R, Wigglesworth JK, Harsha DM, Edwards JE. Efficacy of a home-based training program for older adults using elastic tubing. Eur J Appl Physiol Occup Physiol 1994 69: 316-320. [PubMed]
30.  Hupperets MDW, Verhagen EALM, van Mechelen W. Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial. BMJ 2009 339: b2684. [PubMed]
31.  Berger L, Martinie P, Livain T, Bergeau J, Rougier P. Immediate effects of physiotherapy session of lower limb by balneotherapy on postural control. Ann Readapt Med Phys 2006 49: 37-43. [PubMed]

Address correspondence to: Massimiliano Polastri, Physical Medicine and Rehabilitation, Bologna University Hospital, Sant’ Orsola-Malpighi Polyclinic, Via G. Massarenti, 9. 40138 – Bologna, Italy. Email: gbptap1@gmail.com

1 Physical Medicine and Rehabilitation, Bologna University Hospital, Sant’ Orsola-Malpighi Polyclinic, Bologna, Italy.
2 Orthopedics and Traumatology, Bologna University Hospital, Sant’ Orsola-Malpighi Polyclinic, Bologna, Italy.

© The Foot and Ankle Online Journal, 2012

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Reduction of Ankle Equinus Contracture Secondary to Diabetes Mellitus with Dynamic Splinting

Posted on March 1, 2010 | Comments Off on Reduction of Ankle Equinus Contracture Secondary to Diabetes Mellitus with Dynamic Splinting

by Angel L. Lopez, DPM1, Stanley R. Kalish, DPM2, Mathew M John, DPM3, F. Buck Willis, PhD4

The Foot and Ankle Online Journal 3 (3): 2

Introduction: Ankle equinus is a hereditary or acquired contracture of the triceps surae or shortening of the connective tissue causing inability of the foot to dorsiflex during gait. For the patient population with diabetes mellitus, this high plantar pressure from contracture often results in ulceration. This is frequently treated by Achilles tendon lengthening which helps to avoid infection and amputation. The purpose of this study is to examine the effect of dynamic splinting in reduction of ankle equinus contracture for patients with diabetes mellitus.
Methods: A retrospective analysis was accomplished by reviewing the history of 48 patients following treatment with an ankle dorsiflexion dynamic splint. This dynamic splinting modality delivers low-load prolonged duration stretching while one sleeps. In this home therapy study, dynamic splinting was used for a mean 240 hours in the first month (5 weeks).
Results: Patients showed a statistically significant change in maximal ankle dorsiflexion (P < 0.0001).  The patients mean, maximal active range of motion in dorsiflexion increased by 9º in the first month.
Conclusion: This modality proved effective as home therapy and should be examined in further research so that it may be employed as standard of care in treating ankle equinus contracture.

Key words: Bilateral tension, Dynasplint, Home therapy, Rehabilitation.

Accepted: February, 2010
Published: March, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0303.0002

Ankle equinus is defined as the failure to achieve 10° of dorsiflexion during the gait cycle. [1-10] This disability is the result of contracture and has a significant prevalence in patients who have also been diagnosed with Diabetes Mellitus (DM), both Type 1 and Type 2. [1-4]

Contracture by definition is the molecular shortening of connective tissue and is considered to be the underlying cause of this equinus. [2,3] Contracture of connective tissue is also evident in other pathologies causing other limitations in active range of motion (AROM). [13-19]

Diabetic neuropathy is an underlying neurological condition of ankle equinus contracture when the peroneal nerve is involved. Peroneal nerve atrophy allows the posterior muscle group to overpower the weakened anterior muscles. [3]

In addition, plantar nerve neuropraxia or neurotemesis affecting the posterior tibial nerve (medial and lateral plantar nerves) causes a severe muscle imbalance between the larger and more powerful leg muscles and the intrinsic foot muscles. This contributes to the Lisfranc’s dislocation typically seen in the Charcot diabetic foot. This is similar to the neuromuscular hypertonicity following a stroke which is commonly treated with Botulinium Toxin-A (tone management) and dynamic splinting (for contracture reduction). [13]

A study by Van Gils and Roeder showed the incidence of equinus deformity was present in 91% of patients with DM (n = 151, ages 51-95),1 and a study of 1,666 DM patients by Lavery, et. al., showed 50.3% incidence of ankle equinus (All male; mean age 69 +/- 11 years). [2] National estimates from the American Diabetes Association list the current population of both diagnosed and undiagnosed DM to be 23.7 million Americans and the current “Diabetes-related spending” is $133 billion dollars in the USA. [20]

The current standard of care in treating ankle equinus includes shoe modification,1 ankle mobilization therapy including passive stretching [1-4] and surgery (Achilles tendon lengthening, gastrocnemius recession, or tendon advancement procedures). [1,5,6,11]

The goal of all of these treatments is to prevent the need for amputation following uncontrollable infection from ulceration. The purpose of this study is to examine the effect of dynamic splinting in reduction of ankle equinus contracture for patients with DM.

The Ankle Dorsiflexion Dynasplint® (AFD) (Dynasplint Systems, Inc., Maryland, USA) achieves a low-load, prolonged stretch to reduce contracture through increased time at end range (of motion). [13-19] The Dynasplint® units are worn at night (for 6-8 hours of continuous wear) while sleeping. The Dynasplint® modality has bilateral tension rods that allow for a tissue specific stretch. The device permits dynamic tension settings to be changed, which allow tension to be increased as the end range progresses and the deformity is reduced The AFD used in this study has been shown effective for treating excessive plantar flexion in stroke patients [13] and has shown similar efficacy for treating other conditions requiring contracture reduction. [14-19]

Methods

Records of patients with diagnosed ankle equinus, secondary to DM were used for this retrospective study. Patients’ records who were treated with AFD were retrieved from multiple ankle and foot clinics in Georgia, Texas, and California. Maximal ankle dorsiflexion measurements were the dependent variable and these measurements taken with goniometry while the patient was lying supine with the knee fully extended. The 48 enrolled patients included 25 females and 23 males (mean age of 66 ± Standard deviation 11). The ethnic distribution included 7 African Americans, 4 Asians, 27 Caucasians, and 10 Hispanic patients.

Patients’ initial introduction to the AFD, included customized fitting with consideration for the patient’s foot size and varying degrees of edema which may be present. Patient training was instituted by the technician trained on the Dynasplint systems. Verbal and written instructions were provided throughout the duration of treatment for safety, general wear and care, and tension setting goals based on patient tolerance. (Fig. 1)

Figure 1  Ankle Dorsiflexion Dynasplint®.

Each patient was instructed to start by wearing the AFD for a few hours before sleeping for one day, and then for 6-8 hours while sleeping using an initial tension setting of #1 (2.0 foot pound of torque). This initial frequency, intensity, and duration are used for patient acclimatization to the system. The patients were then instructed to increase the tension one increment every two weeks as tolerated. If the new tension gave the patient “prolonged soreness or pain” (defined as greater soreness than would occur after one hour of intense manual therapy), the patient was instructed to reduce the tension one half increment for a few days before returning to the new setting.

The duration for this study was five weeks. This period was selected to ensure 100% patient compliance and to avoid what one study reported as “difficult (prolonged) follow up.” [4] However the AFD is routinely prescribed for six or more months in treating this condition.

Data Analysis

A paired t-test was calculated to determine if a statistically significant difference existed between the initial, maximal AROM and the final, maximal AROM. The calculations were done independently by an outside biostatistician, Dr Ram Shanmugam from Texas State University, San Marcos, TX.

Results

There was a statistically significant difference in the pre vs. post measurements of patients’ maximal, AROM in dorsiflexion, (p< 0.0001, t = 6.469, df = 47, n = 48). The mean improvement was 20% in just one month. (Fig. 2)

Figure 2  Mean change in active range of motion.

Discussion

The purpose of this study is to examine the effect of dynamic splinting in reduction of ankle equinus contracture for patients with diabetes mellitus. Burke, et al., described hypomobility and diabetic ulcers saying “plantar-flexed first ray deformity (contracture) has been shown to increase pressure on the first metatarsal head and is associated with ulceration.” [5] The AFD used in this trial reduced contracture using passive stretching similar to one component used in the study by Danaberg, et al. The Danaberg study included manual therapy “Mobilization” and passive stretching or “assisted stretching”. The findings show an instant 4.9º improvement in maximal dorsiflexion. [4] Comparable passive stretching was delivered by the AFD but for substantially longer durations as it was worn for 6-8 hours wear during sleep. The AFD wear averaged 6.9 hours per night equaling a total of 241 hours of end range stretching. AROM measurements were taken several hours after awakening which showed stable improvement in contracture reduction.

Literature has shown a direct relationship between mechanical stress (positioning), foot ulceration, and surgery. [3,4,9] Research has also described connective tissue elongation from prolonged stretching [22] and sarcomere changes from limb lengthening. [23] The current standard of care, surgical resolution of ankle equinus contracture, has been established. [1-12] However, use of a modality like the AFD could prevent the need for surgery in a significant number of patients. A previous protocol of using serial casting has been discontinued for DM patients due to the great frequency of skin breakdown and ulcerations from the casting itself. There were no incidences of skin breakdown reported in this retrospective AFD study.

The limitations on this study include lack of a control group, but this study did have high external validity due to the retrospective design which recruited patient records completed before initialization of the study. [21] The study was also limited by its short duration. However, the study by Danaberg, et al., described that a shorter duration study was more likely to display results from the highest patient compliance. This five week study had 100% compliance in wear and tracking of this modality. [4]

Conclusion

Use of the biomechanically correct AFD® with bilateral, dynamic tension has proven effective in this study achieving a mean 9º increase in maximal, active range of motion in one month. This treatment method of dynamic splinting as a home therapy should be considered before surgery is implemented to reduce ankle equinus contracture. In addition, awareness by the physician of these potential damaging equinus factors would suggest early and immediate use of the device for prophylaxis. The normal prescription of this system is six months. A future experiment measuring changes from six month duration in a randomized, controlled trial would prove the efficacy of this modality.

References

1. Van Gils CC, Roeder B. The effect of ankle equinus upon the diabetic foot. Clin Pod Med Surg 2002 Jul; 19(3): 391-409.
2. Lavery LA, Armstrong DG, Boulton AJM. Ankle equinus deformity and its relationship to high plantar pressure in a large population with diabetes mellitus. JAPMA 2002 92: 479-482.
3. Frykberg RG. The high risk foot in diabetes mellitus. New York: Churchill Livingstone, 1991.
4. Dananberg HJ, Shearstone J, Guillano M. Manipulation method for the treatment of ankle equinus. JAPMA 2000 90: 385-389.
5. Birke JA, Patout CA, Foto JG. Factors associated with ulceration and amputation in the neuropathic foot. JOSPT 2000 30(2): 91-97.
6. Menz HB, Dananberg HJ. Manipulation method for the treatment of ankle equinus. JAPMA 2001 91: 105-106.
7. Wallny T, Brackmann H, Kraft C, Nicolay C, Pennekamp P. Achilles tendon lengthening for ankle equinus deformity in hemophiliacs: 23 patients followed for 1-24 years. Acta Orthop 2006 Feb;77(1):164-168.
8. Grady JF, Saxena A. Effects of stretching the gastrocnemius muscle. J Foot Surg 1991 Sep-Oct; 30(5): 465-469.
9. Bowers AL, Castro MD. The mechanics behind the image: foot and ankle pathology associated with gastrocnemius contracture. Semin Musculoskelet Radiol 2007 Mar; 11(1): 83-90.
10. Mullaney MJ, McHugh MP, Tyler TF, Nicholas SJ, Lee SJ. Weakness in end-range plantar flexion after Achilles tendon repair. Am J Sports Med 2006 Jul; 34(7): 1120-1125.
11. Chen L, Greisberg J. Achilles lengthening procedures. Foot Ankle Clin 2009 Dec; 14(4): 627-637.
12. Orendurff MS, Rohr ES, Sangeorzan BJ, Weaver K, Czerniecki JM. An equinus deformity of the ankle accounts for only a small amount of the increased forefoot plantar pressure in patients with diabetes. JBJS 2006 Jan; 88B (1): 65-68.
13. Lai J, Jones M, Willis B. Effect of Dynamic splinting on excessive plantar flexion tone/contracture: A controlled, cross-over study. Proceedings of the 16th European Congress of Physical and Rehabilitation Medicine. Minerva Medica pubs, Italy. 2008 August: 106-109.
14. John MM, Willis FB, Portillo A. Runner’s hallux rigidus reduction and gait analysis, JAPMA 2009 99(4): 367-370.
15. Lundequam P, Willis FB. Dynamic splinting as home therapy for toe walking: A case report. Cases J 2009 Nov 2: 188.
16. Willis FB, John MM, Perez A. Plantar fasciopathy treated with dynamic splinting. PM&R 2009 Sep 1; 9: S169.
17. Sheridan L, Lopez AL, Perez A, John MM, Willis FB. Plantar fasciopathy treated with dynamic splinting: A randomized controlled trial. JAPMA In press.
18. John MM, Kalish SR, Perns SV, Willis, FB. Dynamic splinting for hallux limitus: A randomized controlled trial. JAPMA. In press.
19. Kalish SA, Willis FB. Hallux limitus and dynamic splinting: a retrospective series. The Foot & Ankle Online Journal 2009 Apr; 2 (4): 1.
20. Huang ES, Basu A, O’Grady M, Capretta CJ. Projecting the future diabetes population size and related costs for the U.S. Diabetes Care 2009 Dec; 32 (12): 2225-2229.
21. Kooistra B, Dijkman B, Einhorn TA, Bhandari M. How to design a good case series. JBJS 2009 May; 91A Suppl 3: 21-26.
22. Usuba M, Akai M, Shirasaki Y, Miyakawa S. Experimental joint contracture correction with low torque-long duration repeated stretching. Clin Orthop Relat Res 2007 Mar; 456: 70-78.
23. Makarov M, Birch J, Samchukov M. The role of variable muscle adaptation to limb lengthening in the development of joint contractures: an experimental study in the goat. J Pediatr Orthop 2009 Mar; 29(2):175-181.

Address correspondence to: F. Buck Willis, PhD University of Phoenix: Axia College, Adjunct Professor of Health Sciences, and Dynasplint Systems, Inc. PO Box 1735 San Marcos TX 78667 (512) 297-1833

1  Podiatry; Ft Worth, Texas 910 W North Side Dr Ft Worth, TX 76164. (817) 625-1103 .
2  Atlanta Foot and Leg Clinic, P.A. 6911 Tara Blvd #A Jonesboro, GA 30236-1548 (770) 477-9535
3  Ankle & Foot Centers 2790 Sandy Point Rd. #300 Marietta, GA 30066 (770) 977-3668
4  University of Phoenix: Axia College, Adjunct Professor of Health Sciences, and Dynasplint Systems, Inc. PO Box 1735 San Marcos TX 78667 (512) 297-1833

© The Foot and Ankle Online Journal, 2010

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Dynamic Splinting for Hallux Valgus and Hallux Varus: A Pilot Study

Posted on January 1, 2010 | Comments Off on Dynamic Splinting for Hallux Valgus and Hallux Varus: A Pilot Study

by Mathew M. John, DPM1, F. Buck Willis, PhD2

The Foot and Ankle Online Journal 3 (1): 1

Background: Hallux Abductovalgus (HAV) is a deformity causing excessive angulation of the great toe towards the second toe, and this condition affects over 3.6 million Americans. Conversely hallux varus is excessive medial deviation and this pathology occurs secondary to procedures correcting hallux valgus and as a pediatric/congenital anomaly. The purpose of this pilot study was to report the benefits that Dynamic Splinting (DS) had on reducing contracture in hallux varus and hallux valgus.
Methods: Ten patients treated with DS were examined and these patients included six diagnosed with HAV and four patients diagnosed with hallux varus. The outcome measures reported include changes in maximal, active range of motion (AROM) and resting alignment.
Results: The patients treated for HAV regained a mean 10° active range of motion (AROM) in one month. The patients treated for hallux varus regained a mean 9° AROM in 3 months.
Conclusions: Dynamic splinting was beneficial for all patients in this study. The HAV patients regained a mean 10° of AROM (mean duration 1 month) and the hallux varus patients gained a mean 9° (mean duration 2 months). The modality which delivered low-torque stretching for prolonged durations was effective in reducing these conditions without requiring surgery.

 

Key words: Contracture reduction, Dynasplint, home therapy, rehabilitation.

Accepted: December, 2009
Published: January, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0301.0001

Hallux Abductovalgus (HAV) is a bunion deformity causing abnormal angulation of the great toe towards the second toe. The incidence rate of HAV is 1% of all Americans[1-4] and this includes 9% of women over the age of 60 years old. This pathology causes pain, inflammation, and reduced or impaired functioning of the hallux in ambulation.

The current standard of care in treating this condition includes nonsurgical treatment such as shoe modification followed by surgical management. [5-8] Complications of surgical treatment are not without risk though. Osteotomies of the first metatarsal such as the Lapidus and distal chevron procedure have caused significant incidence of hallux varus.

Hallux varus refers to excessive medial deviation of the great toe. In addition to the frequent iatrogenic postoperative variety, hallux varus occurs as a pediatric/congenital pathology and as a rheumatic or posttraumatic condition. [9,10] This connective tissue pathology is also currently only treated with surgical procedures. [3-6,11]

Similar pathologies have symptomatic contracture which is defined as the molecular shortening of the connective tissue and these pathologies occur from postoperative or posttraumatic arthrofibrosis [12-14], immobilization [15,16], or occur secondarily to excessive neuromuscular tone. [16,17] A study by Usuba, et. al., examined nonsurgical, therapeutic treatments for contracture that was caused by surgical immobilization in rats. [15] After 40 days of surgical immobilization the mean rat knee flexion contracture was -125° (n = 60). Usuba, et. al., then tested the interaction of four protocols: Stretching with high vs. low torque and stretching of prolonged duration vs. short duration. The only statistically significant difference seen between treatment protocols was found with combined protocols of low-torque stretching for prolonged durations.

This combination of low-torque stretching for prolonged durations is exactly what was used in the Dynasplint systems. A study by John, et. al., examined efficacy of the Dynasplint modality for reduction of contracture causing Hallux Limitus (HL). [14] In this study, 50 patients were enrolled after diagnosis of HL which occurred following a bunionectomy or cheilectomy.

The duration of this randomized study was eight weeks, and experimental patients received low-torque, prolonged stretching in the metatarsal joint Dynasplint (MTD) for 60 minutes, three times per day.

The dependent variable in Dr. John’s study was change in Active Range of Motion (AROM) and there was a significant change for the experimental patients following use of this home therapy modality (P < 0.001, T = 4.224). Experimental patients in this study regained a mean 32° change in AROM, extension compared to only a mean 10° change in AROM for control patients. Dr John’s randomized, controlled trial showed conclusive efficacy of the MTD modality.14 A retrospective study (N = 61) by Kalish and Willis showed comparable results in patients’ regaining 73% dorsiflexion at the metatarsal joint after 4 weeks. [13] The purpose of this pilot study was to report the benefits that Dynamic Splinting (DS) had on reducing contracture in hallux varus and hallux valgus.

Methods

Ten patients’ were treated with Dynamic Splinting (DS) in this report, (six with HAV and four with hallux varus). The modality can be seen in Figure 1AB and this unit delivers force and counter force to achieve elongation of connective tissue for contracture reduction. The same unit may be used for both lateral and medial stretching and this alteration is analogous to the Metatarsal Dynasplint that stretches both in plantarflexion[12] and dorsiflexion. [13,14]

Figure 1A and 1B  Hallux valgus (A) and hallux varus (B) Dynasplint.

The initial fitting for patients included customization of the unit (patient’s foot length, girth, and varying degrees of hallux edema), and training on donning and doffing of the devices. Patients also received instruction on safety, general wear and care, and standardized tension setting goals. Dynamic splinting employs the protocol of low-load stretching for contracture reduction through an appropriate biomechanical device which increases the joint’s time at end range (of motion). [12-14,16,17]

Each patient was instructed to wear the DS initially for 10 minutes, three times a day (tid) while seated, with an initial tension setting of #1 (0.10 foot pound of torque). Patients were instructed to sequentially increase the wearing time until they were comfortable wearing the unit for 60 minutes, tid. This lowest intensity was used for becoming accustomed to the system, and the patients were instructed to increase tension on increment every two weeks after they were comfortable wearing the unit for 60 minutes, tid.

Results

The outcome measurements in this study included changes in maximal AROM for all patients and changes in hallux alignment measured in resting, weight bearing position. The patients treated for HAV regained a mean 10° AROM (one month) and the patients treated for hallux varus regained a mean 9° AROM in 3 months. Measurement of hallux alignment was taken while resting (weight bearing). This variable yielded comparable gains of Hallux abduction 10° (HAV) and 9° for adduction (hallux varus).

Conclusion

The purpose of this study was to report the benefits that dynamic splinting had on reducing contracture in hallux varus and hallux valgus. This examination of the new modality for contracture reduction was beneficial in restoring AROM and achieving a more optimal hallux alignment. The DS employed a proven protocol in using low-torque, prolonged stretching to reduce contracture without surgery. [13-17] While surgical resolution of hallux varus and HAV are the current standard of care, therapeutic endeavors have been prescribed effectively for treatment of post operative rehabilitation [18], and the DS used in this study answered the call for therapeutic treatment for hallux contracture pathologies. [3,6,12-14,18]

The use of dynamic splinting in this pilot study caused no adverse events, and a future randomized, controlled trial would determine if this new modality is effective in separate populations of patients with hallux abducto valgus and hallux varus.

References

1. Shima H, Okuda R, Yasuda T, Jotoku T, Kitano N, Kinoshita M: Radiographic measurements in patients with hallux valgus before and after proximal crescentic osteotomy. J Bone Joint Surg 91A (6): 1369 – 1376, 2009.
2. Selner AJ, Selner MD, Cyr RP, Noiwangmuang W: Revisional Am Podiatr Med Assoc 4(4): 341 – 346, 2004.
3. Miller JW: Acquired hallux varus: a preventable and correctable disorder. J Bone Joint Surg 57A (2):183 – 188, 1975.
4. Lui TH: Technique tip: minimally invasive approach of tendon transfer for correction of hallux varus. Foot Ankle Int 30(10): 1018 – 1021, 2009.
5. Miller RJ, Rattan N, Sorto L: The geriatric bunion: correction of metatarsus primus varus and hallux valgus with the Swanson total joint implant. J Foot Surg 22 (3):263 – 270, 1983.
6. Vanore JV, Christensen JC, Kravitz SR, Schuberth JM, Thomas JL, Weil LS, Zlotoff HJ, Mendicino RW, Couture SD; [Clinical Practice Guideline First Metatarsophalangeal Joint Disorders Panel of the American College of Foot and Ankle Surgeons]: Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 3: Hallux varus. J Foot Ankle Surg 42 (3): 137 – 142, 2003.
7. Orzechowski W, Dragan S, Romaszkiewicz P, Krawczyk A, Kulej M, Morasiewicz L: Evaluation of follow-up results of McBride operative treatment for hallux valgus deformity. Ortop Traumatol Rehabil 10(3): 261 – 273, 2008.
8. Jahss MH: Disorders of the hallux and first ray. Disorders of the Foot and Ankle: Medical and Surgical Management. 2nd ed. Philadelphia, Pa: WB Saunders Co, 1084 – 1089, 1991.
9. Trnka HJ, Hofstaetter SG, Easley ME: Intermediate-term results of the Ludloff osteotomy in one hundred and eleven feet. Surgical technique. J Bone Joint Surg 91A (Suppl 2 Pt 1): 156 – 168, 2009.
10. Oloff LM, Bocko AP: Application of distal metaphyseal osteotomy for treatment of high intermetatarsal angle bunion deformities. J Foot Ankle Surg 37(6): 481 – 489, 1998.
11. Bilotti MA, Caprioli R, Testa J, Cournoyer R Jr, Esposito FJ: Reverse Austin osteotomy for correction of hallux varus. J Foot Surg 26 (1): 51 – 55, 1987.
12. John MM, Willis FB, Portillo A: Dynamic splinting for runner’s toe: a case report with gait analysis. J Am Podiatric Med Assoc 99(4): 367 – 370, 2009.
13. Kalish SA, Willis FB: Hallux limitus and dynamic splinting: a retrospective series. The Foot & Ankle Online Journal 2 (4): 1, 2009.
14. John MM, Kalish SR, Perns SV, Willis, FB. Dynamic Splinting for Hallux Limitus: a Randomized, Controlled Trial. Journal American Podiatric Medical Assoc (In-Press)
15. Usuba M, Akai M, Shirasaki Y, Miyakawa S: Experimental joint contracture correction with low torque -long duration repeated stretching. Clin Orthop Relat Res 456: 70 – 88, 2007.
16. Willis FB: Post-TBI Gait rehabilitation. Applied Neurol 3(7): 25 – 26, 2007.
17. Lai J, Jones M, Willis B: Effect of dynamic splinting on excessive plantar flexion tone/contracture: A controlled, cross-over study. Proceedings of the 16th European Congress of Physical and Rehabilitation Medicine. Minerva Medica pubs, Italy, 106 – 109, August, 2008.
18. Schuh R, Hofstaetter SG, Adams SB Jr, Pichler F, Kristen KH, Trnka HJ: Rehabilitation after hallux valgus surgery: importance of physical therapy to restore weight bearing of the first ray during the stance phase. Phys Ther 89(9): 934 – 945, 2009.

Address correspondence to: University of Phoenix: Axia College, Adjunct Professor Health Sciences and Dynasplint Systems, Clinical Research Director.
Email: BuckPhD@yahoo.com

1  Ankle & Foot Centers 2790 Sandy Point Rd. #300 Marietta GA, 30066. (770) 977-3668.
2  University of Phoenix: Axia College, Adjunct Professor Health Sciences, Dynasplint Systems, Clinical Research Director , PO Box 1735 San Marcos TX 78667 (512) 297-1833

© The Foot and Ankle Online Journal, 2010

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