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Following
is a summary list of studies published by Lawrence
M. Fallat, DPM, FACFAS. For complete copies
of any of these studies
contact our office at 313-389-2288.
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Lateral
Column Symptomatology Following Plantar Fascial Release:
A Prospective Study
Annette M. Brugh, DPM, Lawrence M. Fallat,
DPM, FACFAS, and Ruth T. Savoy-Moore, Ph.D
Plantar fasciitis or heel spur syndrome usually resolves with conservative
management, but for patients with continued pain, surgical intervention is
often pursued. In some cases, plantar fasciitis is relieved, but pain in the
lateral column area appears postoperatively. This lateral column pain may
be debilitating for the patient and often overlooked by the foot and ankle
surgeon. The goal of the study was to identify the maximum amount of plantar
fascia that can be surgically released to treat recalcitrant heel pain effectively
while preventing the development of lateral column symptoms. All patients
undergoing plantar fasciotomy after facing conservative treatment were eligible
to participate. Patients rated their pain with an 10-point (0-10 visual analog
scale (VAS) and described its location prior to and at monthly intervals after
their surgery. Surgeons recorded whether 25, 50, or 66% of the plantar fascia
was released during surgery. Open procedures were performed 72% of the time,
and endoscopically in 28% of the patients. Key outcome varibles included
degree of fascial release and foot structure. Patients (n = 47) with lateral
column pain after surgery (n = 15 feet) had a mean S.E. of 60.6 ± 3.0%
of their planter fascia released while those without pain (n = 35 feet) had
only 48.7 ± 1.9% of this fascia released during surgery (ANOVA, p =.019.
Age, weight, body mass index, gender, smoking status, comorbidities, general
health, surgical procedure, postoperative care, calcaneal inclination angle,
and talar declination angle did not differ for these groups (p > .146).
For this patient population, regardless of surgical technique (endoscopic or
release), lateral column symptoms were more likely to result when more
than 50% of the plantar fascia was released. The report proposes that a maximum
of 50% of the plantar fascia be released during surgery. (The Journal of Foot & Ankle
Surgery 41(6):365-371, 2002)
-published in The Journal of Foot & Ankle Surgery 41(6):365-371,
2002
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Correlation
of Heel Pain with Body Mass Index and Other Characteristics
of Heel Pain
James A. Rano, DPM, Lawrence M. Fallat,
DPM, FACFAS, and Ruth T. Savoy-Moore, Ph.D
A prospective, descriptive study was performed at Oakwood Healthcare medical clinics to determine the body mass index (in IM1) of patients with heel pain and of a control group of patients presenting for other reasons. A questionnaire was used to obtain information in each of the patient groups and to determine characteristics of patients with plantar fascial heel pain. Standard weight bearing lateral radiographs were taker to determine overall foot structure. The typical patient was female, had heel pain for just over 1 year with a sedentary to moderate activity level. Although height was comparable, patients with heel pain / ad a higher BMI (30.4 f 0.7) than those without heel pain (28.2 ± 0.7, p = .04). The BMI appears to have a greater role in heel pain than does foot structure, as the authors found no structural commonalities that would explain these patients' pain. Control patients also reported a higher level of activity. Fifty-one percent exercised three or more times per week for more than 20 minutes each time, while less than half that (25.4%) of heel pain patients did so. While half of the heel pain patients had been treated by other providers prior to visiting our clinic, fewer than 25% of these patients had been instructed to lose weight by a physician. The authors feel that a BMI of 25 (the target for decreased cardiovascular risk) represents a reasonable goal for weight loss that may reduce heel pain.
-(The Journal of Foot & Ankle Surgery 40(6):351-356, 2001)
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Computer-Assisted
Assessment of Lateral Column Movement Following Plantar
Fascial Release: A Cadaveric Study
Dawn J. Anderson, DPM,1 Lawrence M. Fallat,
DPM, FACFAS,2 and Ruth T. Savoy-Moore, PhD3
In patients who fail conservative treatment, releasing the plantar fascia
relieves heel pain but destabilizes the lateral column of the foot. After surgery,
pain can present in the area of the sinus tarsi, extensor digitorum brevis
muscle, between the fourth and fifth metatarsals, and at the calcaneocuboid
joint. The precise mechanism and involved structures for this painful compensation
remains unclear. The authors hypothesized that the lateral plantar fascial
band, bifurcate and cervical ligaments, lateral talocalcaneal ligament, and
interosseous talocalcaneal ligament become excessively strained after this
surgery. Using eight cadaver lower extremity limbs amputated 7 cm above the
ankle joint, structural changes in the foot in response to staged release of
the plantar fascia were measured. All ligament, tendon, and osseous structures
were exposed along the plantar, medial, and lateral aspects of the foot and
ankle. Using a servohydraulic system, compressive loads in increasing increments
(50lbs) were applied along the tibia) axis. Tissue and bony structure displacement
in the foot was measured using images electronically captured from two fixed
cameras and a digital camera following each load change. All measurements were
made in pixels and converted to millimeters in a spreadsheet program. Except
for plantar fascial measurements, data were expressed as percentage of initial
baseline. As expected, increasing compressive loads changed all measurements
[repeated measures ANOVA, p < .04].
When releasing the plantar fascia, the
inferior sinus tarsi space widened (intact, 85.4 f 10.8%; 1/4 release, 87.7± 13.0;
1/2 release, 88.3 ± 9.2; 3/4 release, 91.2 ± 8.8; p < .04).
Lateral length increased and medial height decreased, while medial length and
lateral height were unchanged as the fascia was sequentially released. Significant
movement of the inferior sinus tarsi strained the bifurcate and cervical ligaments,
the lateral talocalcaneal ligament, and interosseous talocaneal ligament, which
may account for pain following surgery. The initial 1/4 cut of the plantar
fascia exerted the greatest mechanical alteration of the foot, suggesting that
a partial release may relieve heel pain while optimizing the patient's chances
of maintaining structural integrity with 75% of the plantar fascia intact.
-(The Journal of Foot & Ankle Surgery 40(2):62-70, 2001)
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Biomechanical
Analysis of Maxwell-Brancheau Arthroereisis Implants
Zeeshan S. Husain, DPM,1 and Lawrence M. Fallat,
DPM, FACFAS
The Maxwell-Brancheau arthroereisis (MBA) implant is currently used in treating
flexible flatfoot deformities in children and adults. However, no guidelines
have been established to determine the degree of correction with the five different
MBA implant sizes (6-, 8-, 9-, 10-, and 12-mm diameters). A biomechanical analysis
of these implants was performed in fresh-frozen cadaver limbs to quantitate
the effects on subtalar joint (STJ) motion restriction and radiographic angles.
This study found a restriction of subtalar joint range of motion that ranged
from 32.0 f 5.4%, 44.8 ± 7.7%, 59.0 f 7.2%, 65.5 ± 8.7%, and
76.8 ± 7.6% restriction with successively larger sized implants respectively
(p < .001). Repeated measures analysis of variance (ANOVA) revealed alterations
in the first intermetatarsal, lateral talo-first metatarsal, talar declination,
calcaneal inclination, and first metatarsal declination angles with successively
larger implant use. Analysis of the dorsal talo-first metatarsal, talo-second
metatarsal, lateral talocalcaneal angles, and first to fifth metatarsal head
splay showed no changes as implant size was altered. The study also attempted
to assess the effects on the tendo Achillis when the subtalar joint was changed
from a pronated to a supinated position. The observations showed a 6.33 f 1.40%
(p = .001) increase in tendon length which suggests increased tension to the
tendon. These findings can aid the surgeon in selection of the MBA implant
size based on the desired amount of subtalar joint motion restriction. In turn,
this may reduce errors in the correction of flexible flatfoot with the MBA
implant.
-(The Journal of Foot & Ankle Surgery 41(6):352-358, 2002)
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Cryogenic
Neuroablation for the Treatment of Lower Extremity
Neuromas
Eric F. Caporusso, DPM,1 Lawrence M. Fallat,
DPM, FACFAS,2 and Ruth Savoy-Moore, PhD3
A prospective study testing the efficacy of cryosurgery on lower extremity neuromas was performed. Thirty-one neuromas in 20 patients were percutaneously denervated using a Westco Neurostatin cryoneedle. All patients were surgical candidates who had failed prior conservative treatment. Patient evaluation consisted of a 10-point visual analog scale (VAS) that was administered pre and postoperatively. Periodical evaluation with the VAS and patient satisfaction was conducted for a 1-year period following the procedure. Immediately after the procedure, all patients reported complete relief of pain and were permitted to return to full activity. Two weeks after the index procedure, patients were categorized into one of three groups: those who remained completely pain free (38.7%), those who had reduced pain (45.2%), and those who had reverted to preprocedure pain levels (16.1 %). The pain score of those patients who had reduced pain decreased from a mean of 8.5 ± 0.4 preprocedure to 3.5 ± 0.4 (p < .002). All five patients with no improvement had previous local neurectomies. Even though fewer than 40% of the patients had complete pain relief, an overwhelming 90% stated they would have the procedure performed again. Cryogenic neuroablation appears to be a viable treatment option for patients with lower extremity neuromas. The success rate is similar to surgical excision with little to no disability period and high patient satisfaction.
-(The Journal of Foot & Ankle Surgery 41(5):286-290, 2002)
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The
Tillaux Fracture
Stacey Duchesneau, DPM Lawrence M. Fallat,
DPM, FACFAS
The Tillaux fracture is an avulsion fracture of the distal anterior tibia
tubercle that is seen in adolescents. The authors present a literature review
that includes classification, mechanism of injury, epiphyseal development,
and treatment. Two cases of the Tillaux fracture are presented that represent
patients of different physical maturity and severity of injury, and different
techniques of osteosynthesis.
-(The Journal of Foot and Ankle Surgery 35(2):127-133, 1996)
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Comparison
of Tension Band Wire and Cancellous Bone Screw Fixation
for Medial Malleolar Fractures
Brent A. Johnson, DPM Lawrence M. Fallat,
DPM, FACFAS
A comparison study )f the relative strength of tension-band fixation versus
cancellous bone screw fixation of medial ma leolar ankle fractures was performed
on ten fresh-frozen lower limbs from five cadavers. The mean f )rce recorded
at clinical failure using cancellous screws was 60.98 N (range 33.49 to 117.86
N) compare I with 129.30 N using tension-band fixation (range 85.20 to 194.64
N). Therefore, cancellous screws ex iibited only 47.16% the strength of tension-band
wiring at clinical failure.
-(The Journal of Foot & Anl le Surgery 36(4):284-289, 1997)
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The
Maisonneuve Fracture
Stacey Duchesne au, DPM Lawrence M. Fallat,
DPM, FACFAS
The authors present a review of the mechanism of injury, classification, and surgical fixation techniques of the Maisonneuve fracture. Previous literature is inconsistent regarding operative criteria and appropriate fixation techniques. The authors recommend surgery of the Maisonneuve fracture to maintain reduction and to stabilize the fibula, preventing the shortening with resultant valgus talar shift that can result in painful degenerative ankle arthrosis. Recommendations are also made regarding fixation, based on the severity of the diastasis.
-(The Journal of Foot & Ankle Surgery Volume 34, Number 5, 1995)
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The
Antiglide Plate for the Danis-Weber Type-B Fibular
Fracture: A Review of 71 Cases
Joseph R. Treadwell, DPM Lawrence M. Fallat,
DPM, FACFAS
The authors present a retrospective study of 71 fractures seen in 70 patients who had sustained the Danis-Weber type-B fibular fracture. All patients had the fractures fixated with the posterior antiglide plate. Of the 71 cases studied, 2 developed peroneal tendonitis. No other type of complication related specifically to the antiglide plate was noted. Because of the very low incidence of complications and good biomechanical strength, the authors recommend the antiglide plate for the fixation of type-B fibular fracture.
-(The Journal of Foot & Ankle Surgery Volume 32, Number 6, 1993)
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Dynamic
Unilateral Distraction Fixation: Surgical Management
of Tibial Pilon Fractures
Joseph R. Treadwell, DPM Lawrence M. Fallat,
DPM, FACFAS
The tibia) piton fracture is a severe injury that can result in disastrous
complications. Articulated unilateral external fixation provides an alternate
method for the surgical treatment of intra-articular fractures of the distal
tibia. This technique provides early mobilization of the ankle joint, stabilizes
the fracture site, and through distraction prevents collapse and displacement
of the fracture fragments.
-(The Journal of Foot & Ankle Surgery Volume 33, Number 5, 1994)
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Sprained
Ankle Syndrome: Prevalence and Analysis of 639 Acute
Injuries
Lawrence Fallat, DPM, Douglas J. Grimm, MS,
DPM, and Joseph A. Saracco, DPM
The ankle sprain is often thought of as an injury involving only the lateral ankle ligaments. Frequently other structures area also injured. However, the literature describes only some of the associated injuries. The authors feel that a thorough analysis of each structure injured with the inversion and eversion ankle sprain along with the incidence would be invaluable in making an accurate diagnosis and providing appropriate treatment. The authors conducted a prospective study using a standardized evaluation during the initial examination of patients reporting with an ankle sprain. Over a 33-month period, 639 patients were studied at Oakwood Hospital Downriver Center Emergency Room and Occupational Medicine Clinic. 01' the 639 patients, 92 had an associated avulsion or compression fracture of the foot or ankle. Of the remaining 547 patients, the anterior talofibular ligament was injured 453 times, the calcaneal-fibular ligament was injured 366 times, and the posterior talofibular ligament was injured 187 times. Injuries to the ankle joint capsule were noted in 180 cases, the extensor digitorum brevis was involved in 11 cases, the sinus tarsi was involved in 88 cases, the peroneal tendons in 133 cases, the Achilles tendon in 67 cases, the calcaneal-cuboid ligament in 41 cases, and the syndesmosis was injured in 31 case. Additionally, neuritis was seen in 80 patients presenting with a sprained ankle. Because of the varied and multiple components to the common sprained ankle, the authors feel that this condition would more appropriately be designated as the sprained ankle syndrome. The findings of this study may aid he examiner in exploring a more knowledgeable approach in evaluation, leading to an accurate diagnosis and appropriate treatment.
-(The Journal of Foot & Ankle Surgery 37(4):280-285, 1998)
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Lateral
Ankle Sprains: Evaluation and Treatment
Lawrence Fallat, DPM, Douglas J. Grimm, MS, DPM,
and Joseph A. Saracco, DPM
The increased exposure of podiatric physicians to emergency room trauma, especially
lateral ankle injuries, necessitates immediate knowledge to evaluate and treat
this complex injury. The appropriate knowledge necessary includes the ability
to recognize normal anatomy and variants from pathologic states, either osseous
or soft tissue; the ability to perform specialized tests and their relationship
to the clinical state; and, lastly, the ability to have at grasp various treatment
modalities and the experience to initiate the proper treatment plan.
The intent of this paper is, therefore, to present: normal anatomy of the lateral
ankle and possible anomalies; mechanism of injury of lateral ankle sprains;
performance of specialized tests, especially stress roentgenographs and arthrograms
with examples of normal, normal variants, and abnormal findings; and a review
of the literature of the present state of treatment, as well as the experience
at our institution. Additionally, the authors hope to arrest the thought that
a lateral ankle sprain is a simple soft tissue injury.
-(The Journal of Foot & Ankle Surgery Volume 27, Number 3, 1988)
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Injuries
of the Foot and Ankle in Occupational Medicine: A 1-year
study
Douglas J. Grimm, MS, DPM, and Lawrence Fallat,
DPM
With occupational injuries, both the employee and employer are impaired by monetary or physical damages. Administrative clinical data can assist in identifying risks for these injuries. While musculoskeletal injuries are well known, foot and ankle injuries are not as frequently described as back and hand injuries. Changes in the workplace may then be implemented dependent on the risk factors identified. A retrospective study was completed on all foot and ankle injuries that were reported to the Oakwood Hospital Downriver Center Occupational Medicine Clinics over 1 year. Of 3851 new injuries, 245 (6.4%) were due to foot and ankle injuries. The mean age was 36.7 ± 9.2 (mean ± S.D.) years and 64% men. No seasonal variation was seen. Most commonly the ankle (46.9%) was injured. A diagnosis of sprain was most frequent (40.8%), followed by contusions (26.5%). A twisting mechanism of injury was seen 27.3% oaf the time. Medical charges ranged from $100 to $6414, although over two thirds of the patients had expenses between $250 and $749. Eleven patients required surgery, costing $9125 ± 2321. Most often injured were operators, fabricators, and laborers. Workers were restricted for 20.5 ± 21.4 days, although they were allowed light duty most of the time (16.8 ± 16.5 days).
-(The Journal of Foot & Ankle Surgery 38(2):102-108, 1999)
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Puncture
Wounds: Therapeutic Considerations and A New Classification
Cindy D. Resnick, DPM Lawrence M. Fallat, DPM,
FACFAS
Despite abundant documentation in the literature regarding the complications of puncture wounds, emergency room personal and practitioners alike often under treat this seemingly innocuous injury. The authors present a review of the literature, recommendations for treatment, and a new classification of puncture wounds to aid the clinician in the management of this injury.
-(The Journal of Foot & Ankle Surgery Volume 29, Number 2, 1990)
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Hallux
Fractures: Diagnosis and Treatment
Peter N. Ly, DPM Lawrence Fallat, DPM, FACFAS
The authors present a review of the literature, mechanisms of injury, and
radiographic presentations of hallux fractures. Sixty cases (64 injuries) were
reviewed. Recommendations for treating each type of injury are also presented.
-(The Journal of Foot & Ankle Surgery Volume 31, Number 4, 1992)
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Distal
Tibiofibular Synostosis and Late Sequelae of an Ankle
Sprain
Thomas D. Vitale, DPM, AACFS Lawrence M. RAW,
DPM, FACFAS
The late sequelae of an ankle sprain is described in the form of an acquired
tibiofibular synostosis. A synostosis can result in loss of dynamic motion
between the tibia and fibula, which may create decreased and painful ankle
motion.
A case report and surgical procedure is presented.
-(The Journal of Foot Surgery Volume 29, Number 1, 1990)
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