Insertional Achilles tendinopathy and retrocalcaneal bursitis is difficult to treat, and several operative techniques have been used after failure of conservative management. Dorsal wedge calcaneal osteotomy has been described for the treatment of insertional Achilles pathology. It was hypothesized that dorsal wedge calcaneal osteotomy would be an effective and safe method for the treatment of athletes with insertional Achilles pathology unrelieved by nonoperative measures.
Fifty-two athletes (64 feet) who had painful Achilles tendon syndrome unrelieved by 6 months of nonoperative measures were treated surgically. Dorsally based wedge calcaneal osteotomy was performed through a lateral approach, and 2 staples were used for fixation. Patients were scored pre- and postoperatively with the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot and Victorian Institute of Sports of Australia-Achilles (VISA-A) scores.
At a minimum follow-up of 3 years, the patients’ AOFAS and VISA-A scores improved from 59.5 ± 15.0 and 65.9 ± 11.1 preoperatively to 95.7 ± 6.2 and 90.2 ± 8.4 postoperatively, respectively. Clinical results were considered excellent in 38 patients, good in 12 patients, and fair in 2 patients. Return to previous sports activity time was 21 (SD, 8.0) weeks. One patient necessitated a revision operation.
Operative treatment of insertional Achilles pathology in athletes with dorsal closing wedge calcaneal osteotomy was a safe and effective method that allowed for a quicker return to previous level of sports activities compared with other techniques.
Level IV, retrospective case series
The optimal fixation construct for tibiotalar arthrodesis continues to be debated. While biomechanical data and clinical series support anterior plate augmentation, comparative studies assessing its use are sparse. The purpose of this study was to compare the rates of successful tibiotalar arthrodesis with and without anterior plate augmentation of a compression screw construct.
We studied 64 patients (65 ankles) undergoing tibiotalar arthrodesis done by a single surgeon over a 10-year period (2006-2016) with anterior plate augmentation beginning in 2010. Twenty-six ankles had a construct using compression screws only and 39 ankles had anterior plate augmentation of a compression screw construct. We reviewed clinical notes, operative reports, and postoperative radiographs to evaluate for union, incidence of revision, and postoperative complications.
The nonunion rate in the compression screw (CS) cohort was 15.4% and 7.7% in the anterior plate augmentation (AP) cohort (P = .33). The revision rate was 7.7% in the CS group and 2.6% in the AP cohort (P = .34). The use of autograft harvested through a separate incision was 19.2% and 17.9% in the CS and AP cohorts, respectively. There were 2 deep postoperative infections in the AP group and none in the patients with CS only (P = .24). There were no superficial wound complications in either group.
Anterior plate augmentation was a viable fixation strategy in tibiotalar arthrodesis. In a trend toward an improved rate of fusion and decreased revision rate in the anterior plate augmentation cohort.
Level III, retrospective comparative series.
The effect of ankle positioning during suture-button fixation for syndesmosis repair on range of motion (ROM) and anatomic reduction has yet to be investigated. The purpose of this cadaveric study was to compare the effects of 3 different ankle positions during suture-button repair on volumetric reduction of the syndesmosis, fibular displacement, and ROM of the ankle using 3-dimensional computed tomography (CT) analysis. The null hypothesis was that ankle position during fixation would not affect syndesmotic volume restoration, fibular displacement, or ROM.
Twelve matched pair (n = 24) human cadaveric specimens were used for this study. Prior to syndesmotic sectioning, ROM assessment and CT scans were performed. Following sectioning of the syndesmosis, specimens were repaired in plantarflexion, dorsiflexion, or neutral, and simulated postrepair ROM evaluations and CT scans were repeated. Least squares mean differences between repair groups and the preinjury state were compared by analysis of variance and Tukey’s method.
There were no significant differences between repair groups for volumetric reduction (P = .917), fibular displacement (anterior-posterior, P = .805; medial-lateral, P = .949), or dorsiflexion capacity (P = .249). Among all specimens, compared with the preinjury state, there was a significant mean ± SD volume reduction of 337 ± 400 mm3 and medial displacement of 1.9 ± 1.5 mm.
This study failed to reject the null hypothesis and demonstrated that ankle flexion at the time of syndesmotic fixation with a suture-button construct had no significant in vitro effect on volume changes, fibular displacement, or dorsiflexion capacity. However, in comparison to the preinjured state, suture-button repair resulted in significant overcompression with respect to syndesmosis volume and medial displacement of the fibula.
Ankle position at the time of syndesmotic fixation did not affect overall ankle ROM when using a suture-button construct; however, overcompression was observed in all positions. The clinical impact of syndesmotic overcompression remains largely unknown.
Implant survivorship is dependent on accuracy of implantation and successful soft tissue balancing. System instrumentation for total ankle arthroplasty implantation has a key influence on surgeon accuracy and reproducibility. The purpose of this study was to determine the accuracy and reproducibility of implant position with patient-specific guides for total ankle arthroplasty across multiple surgeons at multiple facilities.
This retrospective, multicenter study included 44 patients who received a total ankle implant (INBONE II Total Ankle System; Wright Medical Technology, Memphis, TN) using PROPHECY patient-specific guides from January 2012 to December 2014. Forty-four patients with an average age of 63.0 years underwent total ankle arthroplasty using this preoperative patient-specific system. Preoperative computed tomography (CT) scans were obtained to assess coronal plane deformity, assess mechanical and anatomic alignment, and build patient-specific guides that referenced bony anatomy. The mean preoperative coronal deformity was 4.6 ± 4.6 degrees (range, 14 degrees varus to 17 degrees valgus). The first postoperative weightbearing radiographs were used to measure coronal and sagittal alignment of the implant vs the anatomic axis of the tibia.
In 79.5% of patients, the postoperative implant position of the tibia corresponded to the preoperative plan of the tibia within 3 degrees of the intended target, within 4 degrees in 88.6% of patients, and within 5 degrees in 100% of patients. The tibial component coronal size was correctly predicted in 98% of cases, whereas the talar component was correctly predicted in 80% of cases.
The use of patient-specific instrumentation for total ankle arthroplasty provided reliable alignment and reproducibility in the clinical situation similar to that shown in cadaveric testing. This study has shown that the preoperative patient-specific instrumentation provided for accuracy and reproducibility of ankle arthroplasty implantation in a cohort across multiple surgeons and facilities.
Level III, retrospective comparative series.
Hallux rigidus is the most common arthritic condition of the foot. A randomized clinical trial of first metatarsophalangeal (MTP) joint hemiarthroplasty with a polyvinyl alcohol (PVA) hydrogel implant (Cartiva) demonstrated pain relief and functional outcomes equivalent to first MTP arthrodesis at 2 years postoperation, with no cases of implant fragmentation, wear, or bone loss. We prospectively determined 5-year outcomes of first MTP hemiarthroplasty with the PVA hydrogel implant.
Patients who underwent first PVA hydrogel MTP hemiarthroplasty in the previously reported trial were evaluated at 5 years postoperatively. Patients underwent physical examination and radiographic evaluation and completed a pain VAS, the Short-Form-36 (SF-36), and the Foot and Ankle Ability Measure (FAAM) sports subscale and activities of daily living (ADL) subscale. At the time of this study, 29 patients had reached 5 years’ follow-up. Two were lost to follow-up, leaving 27 patients with mean age 56.1 (range, 40.1-71.9) years. Mean follow-up was 5.4 (range, 4.9-6.4) years.
Postoperative active MTP natural joint dorsiflexion and peak MTP dorsiflexion were mean 18.2 (range, 10.0-30.0) and 29.7 (range, 10.0-45.0) degrees, respectively. Pain VAS, SF-36 PCS, FAAM ADL, and FAAM Sports scores demonstrated clinically and statistically significant improvements. Radiographically, no patient demonstrated changes in implant position, implant loosening or subsidence, or implant wear. One implant was removed because of persistent pain and converted to fusion 2 years postoperation.
Five years following first MTP hemiarthroplasty with a PVA hydrogel implant, functional outcomes improved significantly, pain was reduced significantly, and the implant demonstrated excellent survivorship.
Level IV, prospective case series.
Measurement of the medial clear space (MCS) is commonly used to assess deltoid ligament competency and mortise stability when managing ankle fractures. Lacking knowledge of the true anatomic width measured, previous studies have been unable to measure accuracy of measurement. The purpose of this study was to determine MCS measurement error and accuracy and any influencing factors.
Using 3 normal transtibial ankle cadaver specimens, deltoid and syndesmotic ligaments were transected and the mortise widened and affixed at a width of 6 mm (specimen 1) and 4 mm (specimen 2). The mortise was left intact in specimen 3. Radiographs were obtained of each cadaver at varying degrees of rotation. Radiographs were randomized, and providers measured the MCS using a standardized technique.
Lack of accuracy as well as lack of precision in measurement of the medial clear space compared to a known anatomic value was present for all 3 specimens tested. There were no significant differences in mean delta with regard to level of training for specimens 1 and 2; however, with specimen 3, staff physicians showed increased measurement accuracy compared with trainees.
Accuracy and precision of MCS measurements are poor. Provider experience did not appear to influence accuracy and precision of measurements for the displaced mortise.
This high degree of measurement error and lack of precision should be considered when deciding treatment options based on MCS measurements.
Plantar plate pathology is common, yet it is unclear whether, and to what extent, the length of the second metatarsal contributes to this problem.
We conducted a retrospective case-control (1:2) study to examine radiographic risk factors for plantar plate tears. One hundred patients (age 55.7 ± 12.3 years) with plantar plate injuries and 200 healthy controls (age 56.3 ± 11.3 years) were included. Cases were defined as patients with nonacute, isolated, plantar plate pathology of the second metatarsophalangeal joint confirmed by intraoperative inspection at a single foot and ankle specialty practice from June 1, 2007, to January 31, 2014. Patients presenting for pain outside of the forefoot served as the control group. Controls were matched on age (±2 years), gender, and year of presentation. Weight-bearing foot x-rays were assessed for several predetermined angular relationships by a single rater. Conditional logistic regression was used to identify risk factors for plantar plate injury.
A long second metatarsal, defined as a metatarsal protrusion index less than –4 mm, was the only significant risk factor for plantar plate pathology in both the univariate and multivariable analyses (multivariate odds ratio 2.5 [95% confidence interval 1.8 to 3.3], P = .002).
We found that a long second metatarsal was a risk factor for developing second metatarsophalangeal joint plantar plate tears. This knowledge may aid foot and ankle surgeons when contemplating the need for second metatarsal shortening osteotomies (eg, Weil osteotomy) during plantar plate surgery and when deciding on the amount of shortening for second metatarsal osteotomies.
Level III, retrospective comparative study.
Subtalar arthritis is a common consequence following calcaneal fracture, and its development is related to the severity of the fracture. Previous calcaneal fracture models have demonstrated altered contact characteristics when a step-off is created in the posterior facet articular surface. Changes in posterior facet contact characteristics have not been previously characterized for calcaneal fracture gap without step-off.
The contact characteristics (peak pressure, area of contact, and centroid of pressure) of the posterior facet of the subtalar joint were determined in 6 cadaveric specimens. After creating a calcaneal fracture to simulate a Sanders type II fracture, the contact characteristics were determined with the posterior facet anatomically reduced followed by an incremental increase in fracture gap displacement of 2, 3, and 5 mm without a step-off of the articular surface.
Peak pressure on the medial fragment was significantly less with a 5-mm gap compared to a 2- or 3-mm gap, or reduced. On the lateral fragment, the peak pressure was significantly increased with a 5-mm gap compared to a 2- or 3-mm gap. Contact area significantly changed with increased gap.
In this study, there were no significant differences in contact characteristics between a <3-mm gap and an anatomically reduced fracture, conceding the study limitations including limiting axial loading to 50% of donor body weight.
A small amount of articular incongruity without a step-off can be tolerated by the subtalar joint, in contrast to articular incongruity with a step-off present.
Lesser metatarsophalangeal (MTP) joint instability is a common cause of forefoot pain. Advances in operative technique and instrumentation have made it possible to anatomically treat plantar plate tears through a dorsal approach. Our goal was to evaluate the subjective, functional, and radiographic outcomes of plantar plate repair (PPR) from a dorsal approach.
A prospective case series was performed evaluating the results of PPR in 97 feet with 138 plantar plate tears. Patients underwent PPR from a dorsal approach with a Weil osteotomy. We followed patients at regular intervals for 12 months and collected data preoperatively and postoperatively with respect to visual analog scale (VAS) scores, MTP range of motion (ROM), paper pull-out test, American Orthopaedic Foot & Ankle Society (AOFAS) scores, satisfaction, and radiographic measures.
Eighty percent of patients scored "good" to "excellent" satisfaction scores at 12 months. The mean VAS pain score preoperatively was 5.4/10, and postoperatively was 1.5/10. The mean AOFAS scores increased from 49 to 81 points following surgery. The mean MTP ROM preoperatively was 43 degrees and postoperatively 31 degrees. Forty-two percent of toes passed the paper pull out test prior to surgery and 54% at 12 months. Mean metatarsal shortening was 2.4/3.1/1.2 mm for the second, third, and fourth metatarsals, respectively. The mean MTP joint angles preoperatively were 2/4.9/–1.3 degrees and postoperatively were 7.4/9.6/0.2 degrees, respectively, for the second, third, and fourth MTP joints.
We found that the plantar plate could be repaired through a dorsal approach with reliable outcomes. PPR was a viable option to anatomically restore the ligamentous support in the unstable lesser MTP joint.
Level of Evidence: Level IV, retrospective case series.
Extensile open approaches to reduce and fix intra-articular calcaneal fractures are associated with high levels of wound complications. To avoid these complications, a technique of percutaneous reduction and fixation with screws alone was developed. This study assessed the clinical outcomes, radiographs, and postoperative CT scans after operative treatment with this technique.
153 consecutive patients with 182 intra-articular calcaneal fractures were reviewed. All patients were assessed for early postoperative complications at 3 months from the injury. The clinical results were assessed for patients seen at a minimum of 1 year after surgery (mean follow-up of 2.6 years; 90 patients, 106 feet). In patients who had both preoperative and postoperative CT scans (50 patients, 60 feet), the articular reduction was quantitatively analyzed.
At the 3-month follow-up, there were 1% superficial infections and 1% rate of screw irritation. The complications at a minimum of 1 year after injury included screw irritation 9.3%, subtalar osteoarthritis requiring subtalar fusion 5.5%, malunion 1.8%, and deep infection 0.9%. Bohler angle, calcaneal facet height, and width were significantly improved postoperatively (P < .01). Bohler angle increased on average +24.1 degrees postoperatively with a loss of angle of 4.9 degrees at the 3-month follow-up. There was significant improvement (P < .01) in posterior talocalcaneal joint reduction on postoperative CT scan but residual displacement remained. At the final follow-up, 54.5% of the patients reported a residual pain level of 3 or lower.
This study suggests that reasonable early results could be achieved from the percutaneous treatment of intra-articular calcaneal fractures using screws alone based on articular reduction and level of residual pain.
Level of Evidence: Level IV, retrospective case series.
Subtalar instability is associated with up to 80% of patients presenting with chronic ankle instability but is often not considered in the diagnosis or treatment. Operative procedures to repair ankle instability have shown good clinical results, but the effects of these reconstruction procedures on isolated subtalar instability are not well understood. The goal of this study was to investigate the effect of the Gould modification of the Broström procedure and a new tenodesis reconstruction procedure on ankle and subtalar joint kinematics after simulating a subtalar injury.
Kinematic data were collected on 7 cadaveric ankles during inversion through the range of ankle flexion and during internal rotation. Testing was performed on the intact foot; after sectioning the calcaneofibular ligament, cervical ligament, and interosseous talocalcaneal ligament; after the Gould modification of the Broström procedure was performed; and after tenodesis was performed and sutures from the Gould modification removed.
The Gould modification of the Broström procedure significantly decreased subtalar and ankle inversion motion and subtalar internal rotation compared to the unstable condition. The tenodesis method restricted internal rotation at the subtalar joint and ankle inversion compared to the intact state.
Both operative procedures improved stability of the ankle complex, but tenodesis was unable to restore subtalar inversion and restricted ankle inversion in maximum plantarflexion.
The Gould modification of Broström ligament repair may be a favorable operative procedure for the restoration of subtalar and ankle joint kinematics.
Diabetes is a risk factor for complications related to displaced ankle fractures. Limited literature exists comparing complication rates in nonoperative versus operative treatment of displaced ankle fractures in diabetics. No study has highlighted the natural history of nonoperative treatment of displaced ankle fractures in diabetics.
We retrospectively reviewed all adult ankle fractures from September 2011 through December 2014. Inclusion was limited to ambulatory adults (>18 years) with closed, displaced (widened mortise) ankle fractures with diabetes mellitus. Nonoperative treatment consisted of closed reduction and casting. Fractures were classified according to the Lauge-Hansen and AO-Weber classification systems. All operative fractures underwent open reduction internal fixation (ORIF) within 3 weeks of injury. Functional outcomes and complication rates were compared. Of 28 displaced diabetic ankle fractures, 20 were treated nonoperatively (closed reduction and casting) and 8 operatively (ORIF within 3 weeks of injury). Mean follow-up was 7 months (range 3-18 months).
Age, insulin-dependent diabetes, and AO type B fracture rate were similar in nonoperative and operative cohorts, but fracture dislocation rate was significantly higher among operative fractures (87.5% vs 40%; P = .04). Nonoperative treatment was associated with a 21-fold increased odds of complication compared with operative treatment (75% vs 12.5%, OR 21.0, P = .004). Complication rate following unintended ORIF for persistent nonunion or malunion in nonoperatively treated patients was significantly greater compared with immediate ORIF (100% vs 12.5%, P = .005).
Nonoperative treatment of displaced diabetic ankle fractures was associated with unacceptably high complication rates when compared to operative treatment.
Level III, retrospective comparative series.
Various methods of midfoot and hindfoot arthrodesis for treating symptomatic Müller-Weiss disease (MWD) have been reported in the literature. In this study, we present the results of a previously unreported method of treatment using a calcaneal osteotomy incorporating a wedge and lateral translation.
Thirteen patients (14 feet) with MWD were treated with a calcaneal osteotomy and retrospectively reviewed. These included 7 females and 6 males, with an average age of 56 years (33-79 years), and an average symptoms duration of 10.6 years (1-16 years). The disease was staged according to Maceira, which included 5 feet in stage II, 4 feet in stage III, 4 feet in stage IV, and 1 foot in stage V. Pre- and postoperative visual analog scale (VAS) score, American Orthopaedic Foot & Ankle Society (AOFAS), radiologic examination, and patients’ satisfaction rate of the surgery were evaluated at an average of 3.7 years (range, 1-8.5 years) following surgery.
The final follow-up visit showed satisfactory outcomes, with VAS score reducing from the preoperative 8 (7-9) to postoperative 2 (0-4), whereas the AOFAS score improved from the preoperative 29 (20-44) to the postoperative 79 (70-88). The patient’s subjective ratings showed excellent results in 4 feet, good results in 8 feet, and fair outcomes in 2 feet. The hindfoot range of motion remained unchanged, as did the extent of the navicular complex arthritis, and no patient required an arthrodesis since surgery.
A calcaneal osteotomy can be used as an alternative treatment option for selected MWD patients regardless of the radiologic stage of the disease.
Level of Evidence: Level IV, retrospective case series.
The aim of this research was to investigate the association of various structural measurements of the forefoot with Morton’s neuroma (MN).
Weightbearing anteroposterior and lateral foot radiographs of subjects attending the University of Western Australia (UWA) Podiatry Clinic and the first author’s private practice were included in this study. A single assessor measured the following angles: lateral intermetatarsal angle (LIMA), intermetatarsal angle (IMA), hallux valgus angle (HVA), digital divergence between the second and third digits (DD23), digital divergence between the third and fourth digits (DD34) and relative metatarsal lengths of the first to fifth metatarsals (Met1-5), and the effect of MN size as measured by ultrasonograph on digital divergence. Intratester reliability of all radiographic measurements was assessed on all radiographic measurements. The study included 101 subjects, of whom 69 were diagnosed with MN and 32 were control subjects without MN. The mean (± standard deviation) age of MN subjects was 52 (±15) years and for control subjects, 48 (±12) years.
When comparing all feet, there were no significant differences in the LIMA, HVA, IMA, digital divergence angles and the relative metatarsal distances between subjects with MN and control subjects. No relationship between MN size and digital divergence was found in either foot, or in either neuroma location.
We were unable to demonstrate any relationship in this study between radiographic metatarsal length and angular measurements in a symptomatic MN group compared to a control group. In addition, we did not find any correlation between the size of MN as measured from ultrasonographic images and radiographic evidence of digital divergence.
Level of Evidence: Level III, case control study.
Ankle fractures in patients with diabetes mellitus (DM) can be difficult to manage, especially in the presence of peripheral neuropathy. In patients who fail initial operative management, attempts at limb salvage can be challenging, and no clear treatment algorithm exists. This study examined outcomes of different procedures performed for limb salvage in this population.
This study retrospectively reviewed 17 patients with DM complicated by peripheral neuropathy who sustained a bimalleolar ankle fracture and failed initial operative management. Patients were treated with revision open reduction internal fixation (ORIF) (3/17), closed reduction external fixation (CREF) (8/17), or primary ankle joint fusion (3/17 tibiotalocalcaneal fusion with hindfoot nail [TTCN] and 3/17 with tibiotalar arthrodesis using plates and screws [TTA]). Median follow-up was 20 months.
The overall rate of limb salvage was 82.3% (14/17). All patients who went on to amputation presented with infection and were treated initially with CREF (3/3). All patients who achieved successful limb salvage ended up with a clinically fused ankle joint (14/14); 9 underwent a primary or delayed formal fusion and 5 had a clinically fused ankle joint at study conclusion after undergoing revision ORIF or CREF with adjunctive procedures.
This small study suggests that in this complicated group of patients it is difficult to achieve limb salvage with an end result of a functional ankle joint. CREF can be a viable option in cases where underlying infection or poor bone quality is present. Treatment with revision ORIF frequently requires supplementary external fixator or tibiotalar Steinman pin placement for additional stability. All patients who underwent revision ORIF ended up with clinically fused ankle joints at the end of the study period. Primary fusion procedures (TTA, TTCN) were associated with a high rate of limb salvage and a decreased number of operations.
Level III, retrospective case series.
The primary aim of this study was to evaluate the outcomes of a series of patients with Charcot neuroarthropathy (CN) who were evaluated in a tertiary care setting. We hypothesized that those patients with CN who presented with a Charcot-related foot wound would have lower rates of successful limb salvage than patients who presented without a wound.
Two hundred forty-five patients (280 feet) were identified with diabetic CN during the time period from January 1, 2005, to June 1, 2015. This consecutive cohort of patients was treated by a single surgeon and had a mean age of 57.9 ± 10.0 years. Our CN patients were divided into 2 groups for the purpose of our analysis. Our study group included those patients who presented to our clinic with a Charcot-related foot wound. Our control group was composed of CN patients who presented without a Charcot-related foot wound.
Overall, 78 feet (27.9%) were successfully treated nonoperatively and 202 feet (72.1%) required some type of surgery. Of the 202 feet that received surgery, 22 (10.9%) were not felt to be suitable for reconstruction and underwent a definitive transtibial amputation without an attempt at reconstruction. An additional 18 patients underwent soft tissue surgery, which included drainage of infection, posterior muscle group lengthening, or soft tissue reconstructive flap surgery. The remaining 162 feet underwent osseous surgery, which included ostectomies for osteomyelitis, exostectomies, osteotomies, and arthrodesis. Eighteen of the 180 limbs (10.0%) that underwent soft tissue or osseous reconstruction ultimately required a transtibial amputation, resulting in a successful limb salvage rate of 90.0%. Thirty-five amputations were performed in 164 feet (21.3%) with Charcot-related foot wounds compared with 5 amputations in 116 feet (4.5%) without Charcot-related foot wounds (OR 6.02, 95% CI 2.28-15.91, P < .0001).
The presence of a Charcot-related foot wound at presentation increased the likelihood of a major lower extremity amputation by a factor of 6. Other risk factors that were associated with major amputation in patients included active infection at presentation, nonunion/instability after reconstruction, and a postoperative wound problem. The overall rate of successful limb salvage in patients deemed reconstructive candidates was 90%.
Level III, retrospective, case-control study.
The extensile lateral approach (EL) has been associated with increased wound complications such as apical necrosis which may be due partially from violation of the lateral calcaneal artery (LCA). Traditionally, the vertical limb has been placed half-way between the fibula and Achilles tendon, which may be suboptimal given the proximity to the LCA. We hypothesized that placing the vertical limb further posterior (ie, modified EL [MEL]) would increase the distance from the LCA. The purposes of this study were to quantify the location of the LCA in relation to the vertical limb of the traditional EL approach and to determine if utilizing the MEL approach endangered the LCA to a lesser extent.
20 cadavers were used. For the EL approach, the fibula and Achilles tendon were palpated and a line parallel to the plantar foot was drawn between the two. A vertical line (VL), representing the vertical limb of the approach, was drawn at the midway point as a perpendicular extending proximally from the junction of the glabrous/non-glabrous skin (JGNG). For the MEL approach, the anterior border of the Achilles tendon was palpated and a similar vertical line (MVL) was drawn 0.75 cm anterior. Dissection was performed and if the LCA was identified crossing the line VL/MVL, the distance from the JGNG was documented.
For the EL approach, the LCA was identified in 17/20 (85%) cadavers at an average distance of 5.0 cm (range 3-7 cm, SD = 1.3 cm) from JGNG. For the ML approach, the LCA was identified in 4/20 (20%) cadavers at an average distance of 5.9 cm (range 3-6.5 cm, SD = 1.7 cm) from the JGNG (P < .001).
The LCA was encountered 4 times more often during the EL approach as compared to the MEL approach.
A modification of the EL approach may decrease iatrogenic injury to the LCA and may decrease wound complications.
Anatomic reduction of ankle fractures may influence outcomes but the relationships between these 2 variables are still unknown and require further investigation. The purpose of this study was to investigate the relationships between radiologic alignment of surgically treated ankle fractures and functional outcomes.
This retrospective study included patients who were surgically treated for Weber B and C ankle fractures. The outcome measures consisted of the Olerud and Molander Ankle Score (OMAS) and the foot and ankle disability measure. Standard radiographs included anteroposterior, lateral, and mortise views of the ankle, both on pre- and postoperatively. Between June 2011 and December 2013, a total of 152 patients were treated for ankle fractures and 76 patients with a mean age of 41.3 ± 17.1 years and a mean follow-up of 39.6 ± 8.9 months were included. There were 45 Weber type B fractures (mean age 43.4 ± 17.8, 28 females, 17 males) and 31 Weber type C fractures (mean age 40.7 ± 17.3, 12 females, 19 males).
Linear regression did not reveal any significant relationships with the exception of age. There was a moderate correlation between the OMAS outcome score and age (r2 = 0.46, P = .01).
We found that younger age was a moderate predictor of functional outcome following surgical treatment of ankle fractures. Radiographic alignment using standard non-weight-bearing radiographs and fracture severity did not predict functional outcomes at 24 months postoperatively.
Level III, prognostic, retrospective cohort study.
Bone graft substitutes are often required in patients at risk for nonunion, and therefore, an allograft that most closely mimics an autograft is highly sought after. This study explored the utility and efficacy of a cellular bone allograft used for foot and ankle arthrodesis and revision nonunion procedures in a patient population at risk for nonunion.
An institutional review board–approved retrospective review of consecutive patients who underwent arthrodesis and revision nonunion procedures with a cellular bone allograft was performed at a single academic institution. No external sources of funding were provided for this study. Inclusion criteria included patients who were more than 1 year after surgery or less than 1 year after surgery if they had undergone a second operative procedure for nonunion or if they had computed tomography–documented union. Forty operative procedures in 36 patients with a mean follow-up of 13 months (range, 6-25 months) were included for data analysis. All patients had at least one of the following risk factors associated with nonunion: current smoker, diabetes, avascular necrosis (AVN) of the involved bone, active same-site operative infection, history of nonunion, previous same-site surgery, or gap of 5 mm or greater after joint preparation. The primary outcome was radiographic union.
The union rate in this high-risk population was 83% (33/40). Univariate analysis demonstrated that the use of a cellular bone allograft helped mitigate the presence of risk factors known to cause nonunion. There was no significant difference in fusion rates among groups with current smoking, AVN of the involved bone, active same-site operative infections, history of nonunion, rheumatoid arthritis on medication, previous same-site operative procedures or infections, or a gap of 5 mm or greater after joint preparation. However, in this population, diabetic and female patients remained at a high risk of recurrent nonunion (P = .0015), despite the use of a cellular bone allograft. Chi-square analysis of patients with increasing numbers of risk factors directly correlated with an increased risk of nonunion (P = .025). Four wound complications were reported in this cohort that required irrigation and debridement (10%).
These data demonstrated a union rate of 83% in patients with risk factors known to cause nonunion. The benefits of the use of a cellular bone allograft allowed for the avoidance of morbidity associated with autograft harvesting while still improving the local biology to facilitate fusion in a difficult patient population to attain a successful fusion mass.
Level IV, retrospective case series.
Surgical site infections (SSIs) are one of the most troublesome complications after foot and ankle surgery. Previous literature has emphasized the significance of appropriate timing of antibiotic prophylaxis. However, the optimal timing of antibiotic prophylaxis for SSI prevention is still inconclusive. Our study aimed to investigate the optimal timing of antibiotic administration and to elucidate the risk factors for SSIs in foot and ankle surgery.
A retrospective review of 1933 foot and ankle procedures in 1632 patients from January 1, 2011, through August 31, 2015, was performed. Demographic data; type, amount, and timing of antibiotic administration; incision; and closure time were recorded. Subsequent wound infection and incision and drainage procedure (I&D) within 30 days and 90 days were documented. Outcomes and demographic variables were compared between procedures in which antibiotics were administered less than 15 minutes and between 15 to 60 minutes prior to incision. A total of 1569 procedures met inclusion criteria.
There were 17 cases (1.1%) of subsequent wound infection, of which 6 required a subsequent I&D within 30 days. There were 63 additional cases (4%) of wound complications, which did not meet SSI criteria. When comparing SSI and non-SSI groups, the only significant independent predictors were longer surgeries and nonambulatory surgeries (both P < .05). Stepwise multivariate logistic regression analysis demonstrated that 91.8% of the risk of an SSI could be predicted by ASA score and length of surgery alone.
In foot and ankle surgeries, the timing of intravenous antibiotic prophylaxis did not appear to play a significant role in the risk of SSI. Host factors and duration of surgery appear to have played a much larger role in SSI than the timing of antibiotic prophylaxis.
Level III, retrospective comparative study.
Arthrodesis of the first metatarsophalangeal (MTP1) joint is an intervention often used in patients with severe MTP1 joint osteoarthritis and relieves pain in approximately 80% of these patients. The kinematic effects and compensatory mechanism of the foot for restoring a more normal gait pattern after this intervention are unknown. The aim of this study was to clarify this compensatory mechanism, in which it was hypothesized that the hindfoot and forefoot would be responsible for compensation after an arthrodesis of the MTP1 joint.
Gait properties were evaluated in 10 feet of 8 patients with MTP1 arthrodesis and were compared with 21 feet of 12 healthy subjects. Plantar pressures and intersegmental range of motion were measured during gait by using the multisegment Oxford Foot Model. Pre- and postoperative X-rays of the foot and ankle were also evaluated.
The MTP1 arthrodesis caused decreased eversion of the hindfoot during midstance, followed by an increased internal rotation of the hindfoot during terminal stance, and ultimately more supination and less adduction of the forefoot during preswing. In addition, MTP1 arthrodesis resulted in a lower pressure time integral beneath the hallux and higher peak pressures beneath the lesser metatarsals. A mean dorsiflexion fusion angle of 30 ± 5.4 degrees was observed in postoperative radiographs.
This study demonstrated that the hindfoot and forefoot compensated for the loss of motion of the MTP1 joint after arthrodesis in order to restore a more normal gait pattern. This resulted in a gait in which the rigid hallux was less loaded while the lesser metatarsals endured higher peak pressures. Further studies are needed to investigate whether this observed transfer of load or a preexistent decreased compensatory mechanism of the foot can possibly explain the disappointing results in the minority of the patients who experience persistent complaints after a MTP1 arthrodesis.
Level III, comparative series.
Open calcaneal osteotomy using traditional methods is associated with complications such as sural nerve injury and potential wound healing problems. We hypothesized that by using novel minimally invasive techniques, these potential risks could be mitigated. This anatomic cadaveric study serves to assess the safety of percutaneous endoscopically assisted calcaneal osteotomy (PECO) compared to a traditional open osteotomy technique.
Anatomic safety of PECO was assessed using 8 fresh-frozen cadaver below-knee specimens. Lateral calcaneal nerve (LCN) damage was primarily noted and then secondly compared to a potential open surgical incision approach.
Only 1 of 11 LCN branches (n = 8 limbs) was transected using PECO, compared to up to 8 of 10 LCN branches (n = 6 limbs) that potentially would have been injured during open surgery.
Percutaneous endoscopically assisted calcaneal osteotomy is a minimally invasive technique that had fewer nerve injuries in this cadaveric model than traditional open surgery.
Percutaneous endoscopically assisted calcaneal osteotomy due to its less invasive nature may result in fewer neurovascular injuries relative to an open procedure.
K-wire fixation has been the most common method of fixation for hammertoe deformity. However intramedullary devices are gaining ground in both number of available choices and in procedures performed. This study aimed to compare the outcomes of hammertoe correction performed with K-wire fixation versus a novel intramedullary fusion device (CannuLink).
A retrospective review of hammertoe correction by a single surgeon was performed from June 2011 to December 2013. Sixty patients (95 toes) underwent K-wire fixation and 39 patients (54 toes) underwent fusion with the CannuLink implant. Average age was 61.7 years and 61.4 years, respectively. Average length of follow-up was 12.9 and 12.3 months, respectively. Patients were evaluated for medical comorbidities, smoking status, inflammatory arthritis, peripheral vascular disease, peripheral neuropathy, pre- and postoperative visual analog pain scale, bony union percentage, revision rate, complications (hardware and surgery-related), and persistent symptoms at last follow-up. There was no significant difference in demographics or comorbidities between the 2 groups (P > .05).
In the K-wire group, 16 patients (18 toes) remained symptomatic at last follow-up (27%). Nine toes (9.5%) had recurrent deformity, 3 toes (3%) developed a late infection because of the recurrent deformity, and 1 toe (1%) developed partial numbness. One patient suffered a calf deep vein thrombosis (DVT) and peroneal nerve neuritis, 1 patient developed foot drop, and 3 patients continued to complain of pain. Five toes required revision surgery (5.3%). In the intramedullary group, 3 (7.7%) patients remained symptomatic and all were associated with a complication. One patient developed chronic regional pain syndrome in the foot, a calf DVT, and a nonfatal pulmonary embolus. A second patient developed a painless recurrent deformity. A third patient had wound dehiscence. Nobody had hardware failure or required a second operation.
The CannuLink intramedullary device for hammertoe correction resulted in fewer complications, only 1 recurrent deformity, and no reoperations compared with K-wire fixation.
Level III, retrospective comparative study.
Several studies have examined the effect of insurance on the management of various orthopedic conditions. The purpose of our study was to assess the effect of insurance and other demographic factors on the operative management of tibiotalar osteoarthritis.
The National Inpatient Sample (NIS) database was used to identify patients who underwent a total ankle arthroplasty (TAA) or tibiotalar arthrodesis (TTA) for tibiotalar osteoarthritis. Insurance status was identified for each patient, and the proportions of each insurance type were computed for each operative modality. A multivariate analysis was performed to account for confounding variables to isolate the effect of insurance type on operative treatment.
From 2007 to 2012, a total of 10 010 patients (35.6%) were identified who underwent a total ankle replacement (TAR) procedure and 18 094 patients (64.4%%) who underwent TTA for tibiotalar osteoarthritis. Patients receiving a TAR were older (65.8 vs 64.2, P < .001), more likely to be female (54% vs 51%, P < .001), and had fewer comorbidities (4.2 vs 4.5, P < .001) than patients who underwent a TTA. After controlling for baseline differences, patients with Medicare (odds ratio [OR] 3.00, P < .001), and private insurance (OR 3.19, P < .001) were approximately 3 times more likely to undergo TAR than patients with Medicaid.
Patients with tibiotalar osteoarthritis were more likely to receive a TAR procedure if they had Medicare or private insurance compared with patients who had Medicaid. Further research should be done to better understand the drivers of this phenomenon if equitable care is to be achieved.
Level II, prognostic study.
We aimed to compare the postoperative height of the second metatarsal head relative to the first metatarsal head using axial radiographs among 3 different commonly used osteotomy techniques: proximal chevron metatarsal osteotomy (PCMO), scarf osteotomy, and distal chevron metatarsal osteotomy (DCMO).
We retrospectively reviewed the radiographs and clinical findings of the patients with painful callosities under the second metatarsal head, complicated by hallux valgus, who underwent isolated PCMO, scarf osteotomy, or DCMO from February 2005 to January 2015. Each osteotomy was performed with 20 degrees of plantar ward obliquity. Along with lateral translation and rotation of the distal fragment to correct the deformity, lowering of the first metatarsal head was made by virtue of the oblique metatarsal osteotomy.
Significant postoperative change in the second metatarsal height was observed on axial radiographs in all groups; this value was greatest in the PCMO group (vs scarf: P = .013; vs DCMO: P = .008) but did not significantly differ between the scarf and DCMO groups (P = .785). The power for second metatarsal height correction was significantly greater in the PCMO group (vs scarf: P = .0005; vs DCMO: P = .0005) but did not significantly differ between the scarf and DCMO groups (P = .832).
Among the 3 osteotomy techniques commonly used to correct hallux valgus deformity, we observed that PCMO yielded the most effective height change of the second metatarsal head.
Level III, retrospective comparative series.
We performed a biomechanical comparison of 2 methods for operative stabilization of pronation-abduction stage III ankle fractures; group 1: Anterior-posterior lag screws fixing the posterior tibial fragment and lateral fibula plating (LSLFP) versus group 2: locked plate fixation of the posterior tibial fragment and posterior antiglide plate fixation of the fibula (LPFP).
Seven pairs of fresh-frozen osteoligamentous lower leg specimens (2 male, and 5 female donors) were used for the biomechanical testing. Bone mineral density (BMD) of each specimen was assessed by means of dual-energy x-ray absorptiometry. After open transection of the deltoid ligament, an osteotomy model of pronation abduction stage III ankle fracture was created. Specimens were systematically assigned to LSLFP (group 1, left ankles) or LPPFP (group 2, right ankles). After surgery, all specimens were evaluated via CT to verify reduction and fixation. Axial load was then applied onto each specimen using a servohydraulic testing machine starting from 0 N (Zwick/Roell, Ulm, Germany) at a speed of 10 N/s with the foot fixed in a 10 degrees pronation and 15 degrees dorsiflexion position. Construct stiffness, yield, and ultimate strength were measured and dislocation patterns were documented with a high-speed camera. The normal distribution of all data was analyzed using Shapiro-Wilk test. The group comparison was performed using paired Student t test. Statistical significance was assumed at a P value of .05.
All specimens had BMD values consistent with osteoporosis. BMD values did not differ between the left and right ankles of the same pair (P = .762). The mean BMD values between feet of men (0.603 g/cm2) and women (0.329 g/cm2) were statistically different (P = .005). The ultimate strength for LSLFP (group 1) with 1139 ± 669 N and LPPFP (group 2) with 2008 ± 943 N was statistically different (P = .036) as well as the yield in LSLFP (group 1) 812 ± 452 N and LPPFD (group 2) 1292 ± 625 N (P = .016). Construct stiffness trended to be higher in group 2 (179 ± 100 kNn) compared to group 1 (127 ± 73 kN/m) but this difference was not statistically significant (P = .120). BMD correlated with bone-construct failure.
Fixation of the posterior tibial edge with a posterolateral locking plate resulted in higher biomechanical stability than anterior-posterior lag screw fixation in an osteoporotic pronation-abduction fracture model.
The clinical implication of this biomechanical study is that the posterior antiglide plating might be advantageous in patients with osteoporotic pronation abduction stage III ankle fracture.
Historically, syndesmosis injuries have been repaired with screw fixation; however, some suggest that suture-button constructs may provide a more accurate anatomic and physiologic reduction. The purpose of this study was to compare changes in the volume of the syndesmotic space following screw or suture-button fixation using a preinjury and postoperative 3-D computed tomography (CT) model. The null hypothesis was that no difference would be observed among repair techniques.
Twelve pairs of cadaveric specimens were dissected to identify the syndesmotic ligaments. Specimens were imaged with CT prior to the creation of a complete syndesmosis injury and were subsequently repaired using 1 of 3 randomly assigned techniques: (a) one 3.5-mm cortical screw, (b) 1 suture-button, and (c) 2 suture-buttons. Specimens were imaged postoperatively with CT. 3-D models of all scans and tibiofibular joint space volumes were calculated to assess restoration of the native syndesmosis. Analysis of variance and Tukey’s method were used to compare least squares mean differences from the intact syndesmosis among repair techniques.
For each of the 3 fixation methods, the total postoperative syndesmosis volume was significantly decreased relative to the intact state. The total mean decreases in volume compared with the intact state for the 1-suture-button construct, 2-suture-button construct, and syndesmotic screw were –561 mm3 (95% CI, –878 to –244), –964 mm3 (95% CI, –1281 to –647) and –377 mm3 (95% CI, –694 to –60), respectively.
All repairs notably reduced the volume of the syndesmosis beyond the intact state. Fixation with 1 suture-button was not significantly different from screw or 2-suture-button fixation; however, fixation with 2 suture-buttons resulted in significantly decreased volume compared with screw fixation.
The results of this study suggest that the 1-suture-button repair technique and the screw fixation repair technique were comparable for reduction of syndesmosis injuries, although both may overcompress the syndesmosis.
Despite the common occurrence of syndesmotic injuries in ankle trauma, the distal tibiofibular relationship remains poorly understood. The aim of this study was to evaluate the anatomical impact of ankle sagittal positioning on the tibiofibular relationship in intact ankles by using a validated magnetic resonance imaging (MRI)–based measurement system.
In this radiologic study, 34 healthy volunteers underwent a series of ankle MRIs with the ankle stabilized in 3 positions: neutral position (NP), dorsiflexion (DF), and plantarflexion (PF). Using a previously validated measurement system, 6 fixed translational measurements and 2 fixed angles were recorded on each MRI and compared using paired t tests.
When comparing PF to DF, the anterior distance between the tibial incisura and the fibula varied from 2.5 mm to 3.9 mm (P < .001), respectively. The middle distance between the tibial incisura and the fibula varied from 1.5 mm to 2.6 mm (P < .001). Fibular angle varied from 8.7 degrees to 7.8 degrees of internal rotation (P = .046), respectively. When comparing NP to DF, only the anterior distance was found to be significantly different, varying 0.4 mm (P < .002).
Ankle dorsiflexion leads to an increase in external rotation and lateral translation of the fibula. These changes could be measured on MRI using a validated measurement system. Ankle motion did have an impact on the distal tibiofibular relationship and should be considered in studies pertaining to syndesmosis imaging.
This is the first in vivo study demonstrating the impact of sagittal ankle position on the distal tibiofibular relationship in an uninjured ankle. Our findings also support the practice of placing the ankle in dorsiflexion when fixing a disrupted syndesmosis.
Level III, comparative study.
Good clinical and radiographic short-term results have been reported for patients who underwent realignment surgery of the hindfoot for treatment of early- and mid-stage ankle osteoarthrosis (OA). However, no mid- to long-term results have been reported. The aim of this study was to gain a better insight into the indications and contraindications for realignment surgery.
Two hundred ninety-four patients (298 ankles) underwent realignment surgery between December 1999 and June 2013. Kaplan-Meier survival analysis was performed with total ankle replacement and arthrodesis of the ankle joint as endpoints. A Cox proportional hazards model was performed to identify risk factors for failure. The mean time to follow-up was 5.0 ± 3.7 years.
The overall 5-year survival rate was 88%. Thirty-eight patients (12.9%) underwent either secondary total ankle replacement or ankle arthrodesis (30 total ankle replacements, 8 ankle arthrodesis). Risk factors for failure following realignment surgery were age at the time of surgery and a Takakura score of 3b preoperatively.
Realignment surgery of the hindfoot was an excellent treatment option for young and physically active patients with early to mid-stage ankle OA.
Level IV, prospective observational study.
Although early accelerated rehabilitation is recommended for the treatment of acute Achilles tendon rupture, most traditional rehabilitation techniques require some type of brace.
We retrospectively analyzed 44 feet of 44 patients (25 male and 19 female) with a mean age of 31.8 years who had an acute Achilles tendon rupture related to athletic activity. Patients had been treated by a double side-locking loop suture (SLLS) technique using double antislip knots between stumps and had undergone early accelerated rehabilitation, including active and passive range of motion exercises on the day following the operation and full weight-bearing at 4 weeks. No brace was applied postoperatively. The evaluation criteria included the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS) score; active plantar flexion and dorsiflexion angles; and the intervals between surgery and the time when patients could walk normally without any support, perform double-leg heel raises, and perform 20 continuous single-leg heel raises of the operated foot.
Despite postoperative early accelerated rehabilitation, the AOFAS score and active dorsiflexion angles improved over time (6, 12, and 24 weeks and 2 years). A mean of 4.3 ± 0.6 weeks was required for patients to be able to walk normally without any support. The mean period to perform double-leg heel raises and 20 continuous single-leg heel raises of the injured foot was 8.0 ± 1.3 weeks and 10.9 ± 2.1 weeks, respectively. All patients, except one who was engaged in classical ballet, could return to their preinjury level of athletic activities, and the interval between operation and return to athletic activities was 17.1 ± 3.7 weeks.
The double SLLS technique with double antislip knots between stumps adjusted the tension of the sutured Achilles tendon at the ideal ankle position and provided good clinical outcomes following accelerated rehabilitation after surgery without the use of a brace.
Level IV, retrospective case series.
Surgical strategies to address deformities of the ankle and hindfoot in patients with Charcot arthropathy include the use of retrograde intramedullary nails and ring fixators. The literature has not shown superiority of one technique over the other. This study presents a single surgeon’s case series of Charcot arthropathy patients treated with either a ring fixator or retrograde intramedullary nail to achieve tibiotalocalcaneal arthrodesis.
We performed a retrospective analysis of 27 consecutive patients with Charcot arthropathy who underwent a tibiotalocalcaneal arthrodesis using either a retrograde intramedullary (IM) nail (n = 16 patients) or a ring fixator (RF) (n = 11 patients) by a single surgeon. We report the rates of limb salvage complications requiring secondary surgery and fusion in both groups. The patient demographics and presence of medical comorbidities known to increase the risk of surgical complications were similar between groups. The mean duration of follow-up for the retrograde nail group was 3.6 years and 2.2 years for the ring fixator group.
The mean time to discharge from the hospital after the index surgical procedure was 2.7 days for the IM group and 4.6 days for the RF group. For the patients treated with a ring fixator, the mean time to removal of the frame after the initial application was 13.3 ± 1.8 weeks. The limb salvage rate for the RF group was 9 of 11 patients whereas it was 15 of 16 in the IM group. Complications including deep infection, hardware failure, and symptomatic nonunion requiring revision surgery were common in the IM group, with 11 of 16 patients requiring further surgery. Seven patients in the IM group required removal of the implant at a mean of 117.2 weeks after the index procedure because of the development of deep infection or nail cutout. In the RF group, only 1 patient required revision surgery. Fusion rates were similar between both groups, with 10 of 16 patients fusing in the IM group and 7 of 11 in the RF group.
Use of a retrograde intramedullary rod or ring fixator resulted in high rates of successful limb salvage when used for tibiotalocalcaneal arthrodesis in patients with Charcot arthropathy. However, in this study, the need for revision surgery was more frequent in the retrograde nail group compared to the ring fixator group.
Level of Evidence: Level III, retrospective comparative series.
Functional recovery following total ankle arthroplasty (TAA) is assessed with patient-reported metrics, but physical performance tests may allow for a more accurate assessment of patient function. We quantified correlations between patient-reported measures and physical performance tests in patients after TAA to determine the usefulness of physical performance tests in post-TAA assessment.
In total, 140 patients with end-stage ankle osteoarthritis were assessed prior to TAA and again at 12 and 24 months postoperatively. At each time point, the visual analog scale (VAS), Foot and Ankle Disability Index (FADI), American Orthopaedic Foot & Ankle Society (AOFAS), Short Musculoskeletal Function Assessment (SMFA), and Short-Form 36 (SF-36) scores were collected, as well as walking speed, Four-Square Step Test (FSST) times, and Short Physical Performance Battery (SPPB) balance scores.
All but 1 (SF-36 general health component) of the patient-reported outcomes improved significantly from preoperative assessment to both 1 and 2 years postoperatively (P < .001 in all cases). Walking speed, FSST times, and balance scores improved significantly across time (P < .001 in all cases). Walking speed was moderately correlated with total SF-36 scores at both 1 and 2 years postoperatively (P < .001 in both cases), both components of the SMFA at 1 year postoperatively (P < .001 in both cases), and total AOFAS scores at 2 years postoperatively (P = .001).
The lack of strong correlations between the 2 sets of metrics indicates that they provide different information about a patient’s recovery following TAA. Therefore, it is important to include both sets of metrics in post-TAA assessments to better understand operative success and functional recovery.
Level of Evidence: Level IV, cohort study.
Biomechanical data and contributions to ankle joint stability have been previously reported for the individual distal tibiofibular ligaments. These results have not yet been validated based on recent anatomic descriptions or using current biomechanical testing devices.
Eight matched-pair, lower leg specimens were tested using a dynamic, biaxial testing machine. The proximal tibiofibular joint and the medial and lateral ankle ligaments were left intact. After fixation, specimens were preconditioned and then biomechanically tested following sequential cutting of the tibiofibular ligaments to assess the individual ligamentous contributions to syndesmotic stability. Matched paired specimens were randomly divided into 1 of 2 cutting sequences: (1) anterior-to-posterior: intact, anterior inferior tibiofibular ligament (AITFL), interosseous tibiofibular ligament (ITFL), deep posterior inferior tibiofibular ligament (PITFL), superficial PITFL, and complete interosseous membrane; (2) posterior-to-anterior: intact, superficial PITFL, deep PITFL, ITFL, AITFL, and complete interosseous membrane. While under a 750-N axial compressive load, the foot was rotated to 15 degrees of external rotation and 10 degrees of internal rotation for each sectioned state. Torque (Nm), rotational position (degrees), and 3-dimensional data were recorded continuously throughout testing.
Testing of the intact ankle syndesmosis under simulated physiologic conditions revealed 4.3 degrees of fibular rotation in the axial plane and 3.3 mm of fibular translation in the sagittal plane. Significant increases in fibular sagittal translation and axial rotation were observed after syndesmotic injury, particularly after sectioning of the AITFL and superficial PITFL. Sequential sectioning of the syndesmotic ligaments resulted in significant reductions in resistance to both internal and external rotation. Isolated injuries to the AITFL resulted in the most substantial reduction of resistance to external rotation (average of 24%). However, resistance to internal rotation was not significantly diminished until the majority of the syndesmotic structures had been sectioned.
The ligaments of the syndesmosis provide significant contributions to rotary stability of the distal tibiofibular joint within the physiologic range of motion.
This study defined normal motion of the syndesmosis and the biomechanical consequences of injury. The degree of instability was increased with each additional injured structure; however, isolated injuries to the AITFL alone may lead to significant external rotary instability.
Operative correction of a symptomatic hallux valgus interphalangeus (HVI) deformity is often achieved with an osteotomy at the proximal end of the proximal phalanx (Akin osteotomy). However, the apex of the typical HVI deformity (center of rotation angle) is at the interphalangeal joint of the hallux. This study was done to evaluate the results of performing a medial closing wedge osteotomy at the distal end of the proximal phalanx.
Thirty-three patients (33 feet) underwent an osteotomy at the distal end of the proximal phalanx for correction of HVI. All of the patients had other forefoot deformities which were corrected at the same time. Eight of these were revision procedures of prior forefoot operations. The length of follow-up was determined by the associated procedures with a minimum follow-up of 4 months.
The preoperative hallux valgus interphalangeus angle averaged 16 degrees of valgus (range 7-32 degrees) and was corrected to an average of 2 degrees of valgus (range 5 degrees valgus to 5 degrees varus). All of the patients were satisfied with the postoperative appearance and function of the first toe. Because of simultaneous correction of numerous other forefoot problems, it was not possible to specifically isolate or evaluate the effects and benefits of this osteotomy using outcomes measures. There was one intraoperative complication resulting in a fracture extending into the adjacent IP joint.
Correction of an HVI deformity can be achieved with an osteotomy at the distal end of the proximal phalanx. This was a safe technique with few complications and with good results in terms of both correction and patient satisfaction.
Level IV, retrospective case series.
Scarf osteotomy has been used in hallux valgus surgery due to its large fixation surface for screws and low postoperative complications. However, screws may cause skin irritation from their head, which may require an additional surgical procedure to remove.
This study included 115 patients (106 females and 9 males, 115 feet) who underwent hallux valgus correction with a scarf osteotomy using bioabsorbable screws between September 2010 and September 2012. Preoperative and postoperative 1-month and 1-year radiographic measurements, including intermetatarsal angle (IMA), hallux valgus angle (HVA), distal metatarsal articular angle (DMAA), proximal phalangeal articular angle (PPAA), and lateral translational distance (LTD), were obtained. American Orthopedic Foot & Ankle Society (AOFAS) hallux/forefoot scores were used for patient satisfaction.
Preoperative mean values of HVA, IMA, and PPA of 32.8 degrees, 14.6 degrees, and 7.52 degrees, respectively, improved to 10.7 degrees, 6.0 degrees, and 4.6 degrees, respectively at 1-year follow up (P < .05). The difference in LTD between the 1-month and 1-year follow-up was not statistically significant. AOFAS hallux/forefoot score improved from 69.1 to 96.1 at the 1-year follow up (P < .001). Complete screw absorption was not seen radiographically. Sixteen feet had complications reported. One patient complained of skin irritation over a small protrusion of the screw, and another patient had a foreign body reaction. There were 3 patients with neurologic injury from a popliteal block and 3 patients with dorsal cutaneous nerve symptoms. Four feet had metatarsal fracture during surgery.
We found the scarf osteotomy using bioabsorbable screws to have satisfactory clinical and radiographic results with a low complication rate.
Level IV, case series.
Significant debate exists regarding optimal repair for unstable syndesmosis injuries. Techniques range from screw fixation, suture-button fixation, or a combination of the two. In this study, 3 common repairs were compared using a simulated weightbearing protocol with internal and external rotation of the foot.
Twenty-four lower leg specimens with mean age 54 years (range, 38-68 years) were used for testing. Following creation of a complete syndesmotic injury (AITFL, ITFL, PITFL, interosseous membrane), specimens were repaired using 1 of 3 randomly assigned techniques: (1) one 3.5-mm syndesmotic screw, (2) 1 suture-button construct, and (3) 2 divergent suture-button constructs. Repairs were cycled for 500 cycles between 7.5 Nm of internal/external rotation torque under a constant 750 N axial compressive load in a neutral dorsiflexion position. At 0, 10, 100, and 500 cycles, torsional cyclic loading was interrupted to assess torsional resistance to rotation within a physiologic range of motion (15 degrees external rotation to 10 degrees internal rotation). Torque (Nm), rotational position (degrees), and 3-dimensional data were collected throughout the testing to characterize relative spatial relationships of the tibiofibular articulation.
There were no significant differences between repair techniques in resistance to internal and external rotation with respect to the intact syndesmosis. Three-dimensional analysis revealed significant differences between repair techniques for sagittal fibular translation with external rotation of the foot. Screw fixation had the smallest magnitude of posterior sagittal translation (2.5 mm), and a single suture-button construct demonstrated the largest magnitude of posterior sagittal translation (4.6 mm). Screw fixation also allowed for significantly less anterior sagittal translation with internal rotation of the foot (0.1 mm) when compared to both 1 (2.7 mm) and 2 (2.9 mm) suture-button constructs.
All repairs provided comparable rotational stability to the syndesmosis; however, no repair technique completely restored rotational stability and tibiofibular anatomic relationships of the preinjury state.
Constructs were comparable across most conditions; however, when repairing injuries with a suture-button construct, a single suture-button construct may not provide sufficient resistance to sagittal translation of the fibula.
Acute complete Achilles tendon ruptures are commonly missed injuries. We propose the Realtime Achilles Ultrasound Thompson (RAUT) test, a Thompson test under ultrasound visualization, to aid in the diagnosis of these injuries. We hypothesized that RAUT testing would provide improved diagnostic characteristics compared with static ultrasound.
Twenty-two consecutive patients with operatively confirmed acute Achilles tendon ruptures were prospectively evaluated with RAUT testing and static ultrasonography. RAUT video recordings and static ultrasound images from both ruptured and uninjured sides were randomized and graded by a group of novice reviewers and a group of expert attendings. From these observations, sensitivity, specificity, positive predictive value, and negative predictive value for RAUT and static ultrasound were calculated. In addition, interobserver coefficients were computed. Forty-seven novice reviewers and 11 foot and ankle attendings made a total of 4136 and 528 observations, respectively.
For static ultrasound, sensitivity and specificity were 76.8% and 74.8% for the novice reviewers and 79.6% and 86.4% for the attendings, respectively. For RAUT testing, sensitivity and specificity were 87.2% and 81.1% for the novice group and 86.4% and 91.7% for the attending group, respectively. The coefficient was 0.62 and 0.27 for novice and attending RAUT reviewers, indicating substantial and fair agreement, respectively, but only 0.46 and 0.12 for static ultrasonography, representing moderate and slight agreement, respectively.
RAUT testing was a sensitive and specific test, providing a cost-effective adjunct to the clinical examination when diagnosing acute Achilles tendon ruptures. This test can be used by surgeons with minimal training in ultrasonography.
Level II, diagnostic study.
Corticosteroid injections have been used for a variety of foot and ankle pathologies over the years, and our aim was to evaluate the efficacy and safety of them in our clinic.
We performed a retrospective review of notes and a telephone questionnaire on the clinical outcome of all patients who underwent a corticosteroid injection of the foot or ankle in a year. All procedures were performed in an outpatient setting by a consultant musculoskeletal radiologist using either ultrasound or X-ray guidance and had a minimum of 2 years of follow-up.
Overall, 314 of 365 (86%) patients reported a significant improvement in symptoms, and 242 (66%) reported complete resolution of their pain, with 107 (29%) remaining asymptomatic at the 2-year follow-up. The mode time of recurrence of pain was 3 months. Fifty-one (14%) underwent a further injection and 88 (24%) underwent operative intervention within the follow-up period. Complication rates in our series were low. There were no reported infections. Complications occurred in 5 patients (1.3%), including steroid flare, pain, and plantar plate ruptures.
Corticosteroid injections were a safe and effective option for treating a variety of foot and ankle conditions and reduced the need for surgery. They were particularly effective for the treatment of ankle soft tissue impingement. They appear ineffective in providing significant improvement in pain for longer than 3 months in conditions such as plantar fasciitis and hallux rigidus.
IV, case series.
The incidence of geriatric ankle fractures has increased during the last few decades. In contrast to younger patients, increased complication rates have been observed. Thus, the goal of the present study was to identify risk factors for perioperative complications following open reduction and internal fixation of geriatric ankle fractures.
Two hundred thirty-seven patients over the age of 65 years (mean, 72.5 ± 6.1 years) treated for ankle fractures in our institution between 2004 and 2014 were included. Complications associated with operative treatment as well as complications requiring revision surgery were analyzed. In a multivariate analysis, risk factors were determined.
In 68 patients (28.7%), 74 complications were documented. The most common complications were impaired wound healing and operative site infections. The multivariate analysis revealed that the operative time was the only independent risk factor for the development of a complication. The operative time as well as the presence of an open fracture represented risk factors for needing revision surgery. Comorbidities did not influence the development of complications.
The operative management of geriatric ankle fractures was associated with a high complication rate. In the present study, the operative time was the only modifiable factor for the development of a complication that required revision surgery. During preoperative preparation, we believe that perfusion of the affected limb should be optimized to reduce the incidence of wound complications.
Level III, retrospective cohort study.
Percutaneous surgery to correct deformities of the forefoot presents the advantages of using a minimal incision, which involves less soft tissue damage and less risk of wound complications. For severe deformities, percutaneous techniques have not been proven as effective. We propose a technique for the treatment of severe hallux valgus.
In a sample of 52 feet operated on 48 patients, we performed a double percutaneous osteotomy (closure proximal osteotomy and a distal Akin) or triple when a Reverdin-Isham osteotomy was added. We measured preoperatively the American Orthopaedic Foot & Ankle Society (AOFAS) score at the 1-year and 2-year follow-up, as well as the values of hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular ankle (DMAA), and shortening and elevation of the first metatarsal. The presence of metatarsalgia was recorded before and after the surgery.
HVA, IMA, and DMAA improved from 39.3 ± 7.1, 17.0 ± 2.0, and 16 ± 8.7 to 11.2 ± 6.2, 8.4 ± 3.4, and 8.3 ± 6.2, respectively. In 5 cases (10%), there was an elevation of the distal metatarsal bone, but only in 2 cases did a transfer metatarsalgia develop. There were no significant correlations between the amount of shortening and the presence of postoperative metatarsalgia. Scores on the AOFAS scale improved from 47.6 ± 5.6 to 89.7 ± 10.1 points.
The results are comparable to those reported with other more established techniques. Transfer metatarsalgia did not correlate with lifting or shortening of the metatarsal. We indicate the percutaneous technique for IMA above 15 degrees and increased DMAA or congruent joints.
Level IV, retrospective case series.
Many authors have reported on patient satisfaction from foot and ankle surgery, but rarely on expectations, which may vary widely between patients and strongly affect satisfaction. In this study, we aimed to develop a patient-derived survey on expectations from foot and ankle surgery.
We developed and tested our survey using a 3-phase process. Patients with a wide spectrum of foot and ankle diagnoses were enrolled. In phase 1, patients were interviewed preoperatively with open-ended questions about their expectations from surgery. Major concepts were grouped into categories that were used to form a draft survey. In phase 2, the survey was administered to preoperative patients on 2 occasions to establish test-retest reliability. In phase 3, the final survey items were selected based on weighted kappa values for response concordance and clinical relevance.
In phase 1, 94 preoperative patients volunteered 655 expectations. Twenty-nine representative categories were discerned by qualitative analysis and became the draft survey. In phase 2, another 60 patients completed the draft survey twice preoperatively. In phase 3, 23 items were retained for the final survey. For retained items, the average weighted kappa value was 0.54. An overall score was calculated based on the amount of improvement expected for each item on the survey and ranged from zero to 100, with higher scores indicating more expectations. For patients in phase 2, mean scores for both administrations were 65 and 66 and approximated normal distributions. The intraclass correlation coefficient between scores was 0.78.
We developed a patient-derived survey specific to foot and ankle surgery that is valid, reliable, applicable to diverse diagnoses, and includes physical and psychological expectations. The survey generates an overall score that is easy to calculate and interpret, and thus offers a practical and comprehensive way to record patients’ expectations. We believe this survey may be used preoperatively by surgeons to help guide patients’ expectations and facilitate shared decision making.
Level II, cross-sectional study.
The objective of this study was to report the results of a new minimally invasive Achilles reconstruction technique and to assess the perioperative morbidity, medium- to long-term outcomes, and functional results.
Our series was comprised 14 patients (11 men and 3 women), with a mean age of 45.6 years at surgery. Each patient had a chronic Achilles tendon rupture. The mean interval from rupture to surgery was 5.5 months (range, 2-10). The mean total follow-up was 30.1 months (range, 12-78). All patients were operated with a central turndown flap augmented with free semitendinosus tendon graft and percutaneous sutures in a minimally invasive approach assisted by endoscopy. The patients underwent retrospective assessment by clinical examination, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score, and the Achilles Tendon Total Rupture Score (ATRS). Paired t tests were used to assess the preoperative and postoperative AOFAS scores, ATRS scores, and ankle range of motion.
The length of the defect ranged from 3 to 8 cm (mean, 5.1), while the length of the turndown flap ranged from 8 to 13 cm (mean, 10.1). The mean AOFAS score improved from 64.5 points preoperatively to 96.9 points at last follow-up. The mean ATRS score improved from 49.4 preoperatively to 91.4 points at last follow-up. None of the patients developed a wound complication. No patient had a rerupture or sural nerve damage.
All patients in our study had a favorable outcome with no complications. We believe that with this triple-repair technique, one can achieve a strong and robust repair such as in open surgery while at the same time reducing the incidence of complications.
Level III, retrospective comparative study.
Suture-button constructs are an alternative to screw fixation for syndesmotic injuries, and proponents advocate that suture-button constructs may allow physiological motion of the syndesmosis. Recent biomechanical data suggest that fibular instability with syndesmotic injuries is greatest in the sagittal plane, but the design of a suture-button construct, being a rope and 2 retention washers, is most effective along the axis of the rope (in the coronal plane). Some studies report that suture-button constructs are able to constrain fibular motion in the coronal plane, but the ability of a tightrope to constrain sagittal fibular motion is unknown. The purpose of this study was to assess fibular motion in response to an external rotation stress test in a syndesmotic injury model after fixation with a screw or suture-button constructs.
Eleven fresh-frozen cadaver whole legs with intact tibia-fibula articulations were secured to a custom fixture. Fibular motion (coronal, sagittal, and rotational planes) in response to a 6.5-Nm external rotation moment applied to the foot was recorded with fluoroscopy and a high-resolution motion capture system. Measures were taken for the following syndesmotic conditions: intact, complete lateral injury, complete lateral and deltoid injury, repair with a tetracortical 4.0-mm screw, and repair with a suture button construct (Tightrope; Arthrex, Naples, FL) aimed from the lateral fibula to the anterior medial malleolus.
The suture-button construct allowed significantly more sagittal plane motion than the syndesmotic screw. Measurements acquired with mortise imaging did not detect differences between the intact, lateral injury, and 2 repair conditions. External rotation of the fibula was significantly increased in both injury conditions and was not restored to intact levels with the screw or the suture-button construct.
A single suture-button placed from the lateral fibula to the anterior medial malleolus was unable to replicate the motion observed in the intact specimen when subjected to an external rotation stress test and allowed significantly more posterior motion of the fibula than when fixed with a screw in simulated highly unstable injuries.
Fixation of a syndesmotic injury with a single suture-button construct did not restore physiological fibular motion, which may have implications for postoperative care and clinical outcomes.
Traditional intraoperative referencing for total ankle replacements (TARs) involves multiple steps and fluoroscopic guidance to determine mechanical alignment. Recent adoption of patient-specific instrumentation (PSI) allows for referencing to be determined preoperatively, resulting in less steps and potentially decreased operative time. We hypothesized that usage of PSI would result in decreased operating room time that would offset the additional cost of PSI compared with standard referencing (SR). In addition, we aimed to compare postoperative radiographic alignment between PSI and SR.
Between August 2014 and September 2015, 87 patients undergoing TAR were enrolled in a prospectively collected TAR database. Patients were divided into cohorts based on PSI vs SR, and operative times were reviewed. Radiographic alignment parameters were retrospectively measured at 6 weeks postoperatively. Time-driven activity-based costing (TDABC) was used to derive direct costs. Cost vs operative time-savings were examined via 2-way sensitivity analysis to determine cost-saving thresholds for PSI applicable to a range of institution types. Cost-saving thresholds defined the price of PSI below which PSI would be cost-saving. A total of 35 PSI and 52 SR cases were evaluated with no significant differences identified in patient characteristics.
Operative time from incision to completion of casting in cases without adjunct procedures was 127 minutes with PSI and 161 minutes with SR (P < .05). PSI demonstrated similar postoperative accuracy to SR in coronal tibial-plafond alignment (1.1 vs 0.3 degrees varus, P = .06), tibial-plafond alignment (0.3 ± 2.1 vs 1.1 ± 2.1 degrees varus, P = .06), and tibial component sagittal alignment (0.7 vs 0.9 degrees plantarflexion, P = .14). The TDABC method estimated a PSI cost-savings threshold range at our institution of $863 below which PSI pricing would provide net cost-savings. Two-way sensitivity analysis generated a globally applicable cost-savings threshold model based on institution-specific costs and surgeon-specific time-savings.
This study demonstrated equivalent postoperative TAR alignment with PSI and SR referencing systems but with a significant decrease in operative time with PSI. Based on TDABC and associated sensitivity analysis, a cost-savings threshold of $863 was identified for PSI pricing at our institution below which PSI was less costly than SR. Similar internal cost accounting may benefit health care systems for identifying cost drivers and obtaining leverage during price negotiations.
Level III, therapeutic study.
This study examined the effect of botulinum toxin upon plantar fasciitis through a randomized, controlled, and blinded trial.
Between 2012 and 2015, 50 patients presented with plantar fasciitis. Twenty-five patients each randomly received an IncobotulinumtoxinA (IBTA) or saline injection of their affected foot. Pre- and postinjection function and pain were graded with the Foot and Ankle Ability Measures (FAAM) and visual analog scale (VAS), respectively. All 50 study patients who randomly received either placebo or IBTA presented at 6 and 12 months after injection.
At 6 months, the mean FAAM increased from 35.9 to 40.9 of 100, and the mean pain score decreased from 8.4 to 7.9 of 10 within the placebo group. At 6 months, the mean FAAM increased from 36.3 to 73.8 of 100, and mean pain score decreased from 7.2 to 3.6 of 10 within the IBTA group. These postinjection scores were significantly better than the placebo group (P = .01). At 12 months after injection, the IBTA group maintained significantly better function and pain than the placebo group (P < .05). By that time, 0 (0%) and 3 (12%) patients who received IBTA and saline, respectively, underwent surgery for recalcitrant plantar fasciitis (P < .005).
Compared with placebo saline injection, using IBTA to treat plantar fasciitis resulted in significantly better improvement in foot function and pain. IBTA also lessened the need for operative treatment of plantar fasciitis.
I, Randomized, double-blinded, placebo-controlled study.
Complex anesthesia is increasingly used in order to reduce postoperative pain and accelerate rehabilitation. The aim of this study was to evaluate the efficacy and safety of preemptive local anesthesia combined with general or spinal anesthesia in ankle arthroscopy.
From January 2014 to February 2016, 80 ankle anterior arthroscopies were performed. Patients were randomly assigned to one of 4 groups, depending on the type of anesthesia: A, general and local preemptive; B, spinal and local preemptive; C, general and placebo; D, spinal and placebo. After general or spinal anesthesia, each patient randomly received an injection of 7 mL of a mixture of local anesthetics or the same amount of normal saline. After 2, 4, 8, 12, 16, 24, 48, and 72 hours following the release of the tourniquet, the pain intensity level was measured with a visual analog scale (VAS). The use of additional analgesics and any adverse effects were also noted.
Preemptive local anesthesia (groups A and B) resulted in a significantly lower level of pain intensity during the first 24 hours after surgery. Until 8 hours after the release of the tourniquet, the pain intensity level was statistically lower in the groups A, B, and D in comparison to C. During hospitalization, none of the patients from groups A and B received on-demand ketoprofen intravenously. No side effects of local anesthetic agents were observed. Two patients had transient numbness and paresthesia in the field of sensory nerve innervation of the dorsal intermediate cutaneous nerve of the foot.
Preemptive operative site infiltration with a mixture of local anesthetics performed in ankle arthroscopy was a safe procedure. It reduced the level of intensity of postoperative pain and the amount of analgesics used.
Level I, prospective randomized study.
Hallux valgus is frequently associated with additional forefoot pathologies, including hammertoes and midfoot osteoarthritis (OA). However, the pathogenesis of these concurrent pathologies remains to be elucidated. We sought to determine whether there is a relationship between demographic and radiographic parameters and the incidence of secondary pathologies in the setting of a bunion, with an emphasis on second tarsometatarsal (TMT) OA and hammertoes.
A total of 153 patients (172 feet) who underwent reconstruction for hallux valgus were divided into 3 groups: (1) bunion only (61 patients), (2) bunion with hammertoe without second TMT joint OA (78 patients), and (3) bunion with second TMT joint OA (14 patients). Preoperative age, sex, and body mass index (BMI) as well as hallux valgus angle (HVA), intermetatarsal angle (IMA), metatarsus adductus angle (MAA), ratio of second to first metatarsal length, and Meary’s angle were recorded. One-way analysis of variance (normality demonstrated) and Kruskal-Wallis (normality not demonstrated) tests were used to assess differences in continuous variables. Post hoc tests were conducted with the Bonferroni technique. Associations between discrete variables and the study groups were analyzed using 2 tests. Following the univariate analysis, multinomial logistic regression models were built to determine potential risk factors for hammertoe or TMT OA group placement.
Patients in the hammertoe and TMT OA groups were significantly older than patients in the bunion only group (P < .001 for both pairwise comparisons) and had significantly higher BMIs (P = .024 and P < .001, respectively). Patients in the TMT OA group had a significantly higher mean HVA than patients in the bunion-only group (P = .004) and a significantly higher mean MAA relative to both other study groups (P ≤ .001 for both comparisons). IMA, Meary’s angle, and the ratio of second to first metatarsal length did not differ significantly between groups. In the multivariate analysis, hammertoe group assignment was predicted only by age and HVA, while midfoot OA group assignment was predicted by age, HVA, BMI, and MAA.
Our data show that older age and increased HVA were predictors of both second ray pathologies studied. Higher BMI and MAA were predictive only of TMT joint OA. These data may help identify patients with hallux valgus who are at greater risk for developing secondary pathologies.
Level III, retrospective comparative series.
Although gastrocnemius recession has been proposed and used in the treatment of chronic noninsertional Achilles tendinopathy, only weak evidence exists to support this operative indication. The purpose of our study was to assess the clinical and functional outcomes of patients treated with gastrocnemius recession at 2 institutions for this problem.
Thirty-four patients were identified through our medical records and asked to participate in this study. Thirty patients (35 legs) responded to the invitation. Sixteen patients were eligible for clinical follow-up, and 14 patients responded by letter or telephone interview. Two patients did not want to participate, and 2 patients could not be reached. Data were collected by a satisfaction questionnaire, the Victorian Institute of Sports Assessment–Achilles (VISA-A) questionnaire, a visual analog scale (VAS) for pain, a functional test battery, and a clinical examination.
A subgroup with preoperative data (n = 8) showed an increase in the mean VISA-A score from 39.5 to 91.9. The mean overall VISA-A score (n = 30) was 91.4 at follow-up. The mean VAS for pain score when walking decreased from 7.5 before surgery to 0.8 after surgery. Twenty-eight of 30 patients reported that they were satisfied with their results after surgery. Functional testing showed no difference in gastrocnemius-soleus function between the operated and nonoperated leg (n = 10).
The findings support the promising results from other studies regarding gastrocnemius recession as an effective and safe way of treating chronic Achilles tendinopathy. The patients recovered both in terms of pain and function.
Level IV, retrospective case series.
Joint compression is an essential element of successful arthrodesis. Although subtalar joint compression generated by conventional screws has been quantified in the laboratory, compression obtainable with headless screws that rely on variable thread pitch to achieve bony contact has not been assessed. This study measured subtalar joint compression achieved by 2 posteriorly placed contemporary headless, variable-pitch screws, and quantified additional compression gained by placing a third screw anteriorly.
Ten, unpaired fresh-frozen cadaveric subtalar joints were fixed sequentially using 2 diverging posterior screws (one directed into the talar dome, the other into the talar neck), 2 parallel posterior screws (both ending in the talar dome), and 2 parallel screws with an additional anterior screw inserted from the plantar calcaneus into the talar neck. Joint compression was quantified directly during screw insertion using a novel custom-built measuring device.
The mean compression generated by 2 diverging posterior screws was 246 N. Two parallel posterior screws produced 294 N of compression, and augmentation of that construct with a third, anterior screw increased compression to 345 N (P < .05). Compression subsequent to 2-screw fixation was slightly less than that reported previously for subtalar joint fixation with 2 conventional lag screws, but was comparable when a third screw was added.
Under controlled testing conditions, 2 tapered, variable-pitch screws generated somewhat less compression than previously reported for 2-screw fixation with conventional headed screws. A third screw placed anteriorly increased compression significantly.
Because headless screws are advantageous where prominent screw heads are problematic, such as the load-bearing surface of the foot, their effectiveness compared to other screws should be established to provide an objective basis for screw selection. Augmenting fixation with an anterior screw may be desirable when conditions for fusion are suboptimal.
Fresh osteochondral allografting of the talus is one treatment option for large chondral defects. Following positive early term results, failure rates of up to 35% have been reported. A retrieval study was performed to characterize failed talar allografts.
Failed fresh osteochondral allografts of the talus were retrieved on revision. Cases of deep infection were excluded. After tissue fixation, samples were decalcified, embedded, and stained with Safranin-O/Fast Green, osteocalcin, tumor necrosis factor alpha (TNF-α), CD4, CD8, and CD68. Slides were graded according to the modified Mankin scoring system or severity scale. Medical record review was performed.
Eight allografts (7 patients) were retrieved from patients, following an average term of implantation of 31 months (range, 12-58). There were 3 types of allografts in this series (hemidome, n=5; segmental, n=2; bipolar, n=1). Reasons for transplantation were post-traumatic arthritis or osteonecrosis; reasons for revision were graft failure/collapse, nonunion, progressive arthritis, and/or pain. Prior to revision, all grafts exhibited collapse and subchondral lucencies. At the graft host interface, Safranin-O staining demonstrated substantial loss of sulfated glycosaminoglycans, Osteocalcin immunostaning was nearly absent, CD68 (indicating osteoclast activity) was predominantly exhibited, and CD4+ helper T cells as well as CD8+ cytotoxic T cells and NK cells—cell types commonly implicated in allogeneic organ transplant rejection—were found in high concentrations. TNF-α was present throughout the graft.
A histopathologic analysis of 8 retrieved, failed talar allografts was performed. Graft failure appeared to be primarily biologic, with an extensive loss of viable cartilaginous and osseous tissue at the graft-host interface. This study provides the first evidence of a potential CD4+ and CD8+ lymphocyte-mediated failure mechanism in fresh osteochondral allografts that were revised following collapse.
Level IV, case series.
This study was conducted to evaluate the outcomes of patients with diabetic foot osteomyelitis (DFO) compared to diabetic foot soft tissue infections (STIs).
229 patients who were hospitalized with foot infections were retrospectively reviewed, identifying 155 patients with DFO and 74 patients with STI. Primary outcomes evaluated were the rates of amputations and length of hospital stay. DFO was confirmed by the presence of positive bone culture and/or histopathology. Results: Patients with DFO had a 5.6 times higher likelihood of overall amputation (P < .0001), a 3.4 times higher likelihood of major amputation (P = .027) and a 4.2 times higher likelihood of minor amputation (P < .0001) compared to patients without DFO. Major amputation was performed in 16.7% patients diagnosed with DFO and 5.3% of patients diagnosed with STI. Patients with DFO complicated by Charcot neuroarthropathy had a 7 times higher likelihood of undergoing major amputation (odds ratio 6.78, 95% confidence interval 2.70-17.01, P < .0001). The mean hospital stay was 7 days in DFO and 6 days in patients with DFI (P = .0082). Patients with DFO had a higher erythrocyte sedimentation rate (85 vs 71, P = .02) than patients with STI, however the differences in C-reactive protein (13.4 vs 11.8, P = .29) were not significantly different.
In this study of moderate and severe DFIs, the presence of osteomyelitis resulted in a higher likelihood of amputation and longer hospital stay. Readers should recognize that the findings of this study may not be applicable to less severe cases of DFO that can be effectively managed in an outpatient setting.
Level III, retrospective comparative case series.
An os trigonum is a potential source of posterior ankle pain in dancers, often associated with flexor hallucis longus (FHL) pathology. Options for operative excision include open excision, subtalar arthroscopy, and posterior endoscopy. The purpose of this paper was to present a series of dancers who underwent excision of a symptomatic os trigonum via an open posteromedial approach.
This study is a retrospective case series of 40 ankles in 38 dancers who underwent os trigonum excision via an open posteromedial approach with FHL tenolysis between 2000 and 2013. All patients were interviewed and charts retrospectively analyzed. Collected variables included pre- and postoperative pain level, time to return to dance, and subjective satisfaction. The average age was 19.2 years; ballet was the primary dance form in 36 (95%) of patient-cases. Eight (20%) of the patient-cases were professional dancers, and 30 (75%) were students or preprofessional dancers.
Average preoperative pain level was 7.7/10, which decreased to 0.6/10 postoperatively. Seventeen (42.5%) experienced concurrent preoperation-associated FHL symptomatology, all of whom experienced relief postoperatively. The average time to return to dance was 7.9 weeks, and time to pain-free dance was 17.7 weeks. Of the 37 patient-cases desiring to return to dance, 35 (94.6%) returned to their preoperative level of dance. There were no neurovascular or other major complications. Four (10%) had minor wound complications that resolved, and 38 cases (95%) considered the procedure a success.
Open posteromedial excision of an os trigonum in dancers provided satisfactory pain relief, return to dance, and complication rates compared to other approaches, and allowed for identifying and treating any associated FHL pathology.
Level IV, retrospective case series.
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.
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.
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.
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 II, prospective comparative study.
Increased surgeon volume may be associated with improved outcomes following operative procedures. However, there is a lack of information on the effect of surgeon volume on inpatient adverse events and resource utilization following total ankle arthroplasty (TAA).
A retrospective cohort study of TAA patients was performed using the Nationwide Inpatient Sample (NIS) from 2003 to 2009. High-volume surgeons were considered as those with volume ≥90th percentile of surgeons performing TAA. Multivariate regression was used to compare the rates of adverse events, hospital length of stay, and total hospital charges between surgeon volume categories.
A total of 4800 TAA patients were identified. The 90th percentile for surgeon volume was 21 cases per year. Mean length of stay was 2.8 ± 2.3 days and mean hospital charges were $45 963 ± $43 983. On multivariate analysis, high-volume surgeons had decreased overall complications (OR 0.5, P = .034) and rate of medial malleolus fracture (OR 0.1, P = .043), decreased length of stay (–0.9 days, P < .001), and decreased hospital charges (–$20 904, P < .001).
Surgeons with volume ≥90th percentile had a decreased rate of complications, decreased length of stay, and reduced hospital charges compared to other surgeons.
Level III, comparative study.
Repeated surgery can be a measure of failure of the primary surgery. Future reoperations might be avoided if the cause is recognized and procedures or devices modified accordingly. Reoperations result in costs to both patient and the health care system. This paper proposes a new classification system for reoperations in end-stage ankle arthritis, and analyzes reoperation rates for ankle joint replacement and arthrodesis surgeries from a multicenter database.
A total of 213 ankle arthrodeses and 474 total ankle replacements were prospectively followed from 2002 to 2010. Reoperations were identified as part of the prospective cohort study. Operating reports were reviewed, and each reoperation was coded. To verify inter- and intraobserver reliability of this new coding system, 6 surgeons experienced in foot and ankle surgery were asked to assign a specific code to 62 blinded reoperations, on 2 separate occasions. Reliability was determined using intraclass correlation coefficients (ICCs) and proportions of agreement.
Of a total of 687 procedures, 74.8% (514/687) required no reoperation (Code 1). By surgery type, 14.1% (30/213) of ankle arthrodesis procedures and 30.2% (143/474) of ankle replacement procedures required reoperation. The rate for reoperations surrounding the ankle joint (ie, Codes 2 and 3) was 9.9% (21/213) for ankle arthrodesis versus 5.9% for ankle replacement (28/474). Reoperation rates within the ankle joint (ie, Codes 4 to 10) were 4.7% (10/213) for ankle arthrodesis and 26.1% (124/474) for ankle replacement. Overall, 0.9% (2/213) of arthrodesis procedures required reoperation outside the initial operative site (Code 3), versus 4.6% (22/474) for total ankle replacement. The rate of reoperation due to deep infection (Code 7) was 0.9% (2/213) for arthrodesis versus 2.3% (11/474) for ankle replacement. Interobserver reliability testing produced a mean ICC of 0.89 on the first read. The mean ICC for intraobserver reliability was 0.92. For interobserver, there was 87.9% agreement (804/915) on the first read, and 87.5% agreement (801/915) on the second. For the intra observer readings, 88.5% (324/366) were in agreement.
The new coding system presented here was reliable and may provide a more standardized, clinically useful framework for assessing reoperation rates and resource utilization than prior complication- and diagnosis-based classification systems, such as modifications of the Clavien Dindo System. Analyzing reoperations at the primary site may enable a better understanding of reasons for failure, and may therefore improve the outcomes of surgery in the future.
Level III, retrospective comparative cohort study based on prospectively collected data.
The "tibiofibular line" is a new axial computed tomography parameter for assessing syndesmosis reduction, which references the flat anterolateral surface of the fibula and anterolateral tibial tubercle. These same bony landmarks are easily visualized via a lateral approach to the fibula. This cadaveric study assessed the practical aspects of measuring the tibiofibular line intraoperatively.
Three observers simulated the tibiofibular line using operative rulers in 3 measurement series utilizing 10 cadaveric specimens: intact syndesmosis, syndesmosis reduction, and fixation after application of lateral plate and screws to the fibula, and post syndesmosis reduction and fixation without plate and screws.
The majority (78%) of clinical tibiofibular line measurements were within the "normal" range (0-2 mm). However, there was a general trend toward malreduction (>2 mm) across measurement series. Intraobserver variability ranged from poor to excellent (intraclass correlation range, 0.12-0.85, Fleiss kappa range, 0.19-0.40) and interobserver reliability was only generally in the fair range (intraclass correlation range, 0.49-0.61; Fleiss kappa range, 0.19-0.40).
Taken as a whole, these findings found that the technique was feasible but clearly indicated that further refinement of this protocol, including the use of computed tomography, would be needed to determine if better control of confounding variables would reveal better observer reliability.
The CT-based TFL technique for syndesmosis reduction assessment could not reliably be translated into an intraoperative open technique because of the confounding effects of subjectivity and operator error.
In 1976, Ramsey and Hamilton published a landmark cadaveric study demonstrating a dramatic 42% decrease in tibiotalar contact area with only 1 mm of lateral talar shift. An increase in maximum principal stress of at least 72% is predicted based on these findings though the delayed development of arthritis in minimally misaligned ankles does not appear to be commensurate with the results found in dry cadaveric models. We hypothesized that synovial fluid could be a previously unrecognized factor that contributes significantly to stress distribution in the tibiotalar joint in anatomic and injured states.
As it is not possible to directly measure contact stresses with and without fluid in a cadaveric model, finite element analysis (FEA) was employed for this study. FEA is a modeling technique used to calculate stresses in complex geometric structures by dividing them into small, simple components called elements. Four test configurations were investigated using a finite element model (FEM): baseline ankle alignment, 1 mm laterally translated talus and fibula, and the previous 2 bone orientations with fluid added. The FEM selected for this study was the Global Human Body Models Consortium–owned GHBMC model, M50 version 4.2, a model of an average-sized male (distributed by Elemance, LLC, Winston-Salem, NC). The ankle was loaded at the proximal tibia with a distributed load equal to the GHBMC body weight, and the maximum principal stress was computed.
All numerical simulations were stable and completed with no errors. In the baseline anatomic configuration, the addition of fluid between the tibia, fibula, and talus reduced the maximum principal stress computed in the distal tibia at maximum load from 31.3 N/mm2 to 11.5 N/mm2. Following 1 mm lateral translation of the talus and fibula, there was a modest 30% increase in the maximum stress in fluid cases. Qualitatively, translation created less high stress locations on the tibial plafond when fluid was incorporated into the model.
The findings in this study demonstrate a meaningful role for synovial fluid in distributing stresses within the ankle that has not been considered in historical dry cadaveric studies. The increase in maximum stress predicted by simulation of an ankle with fluid was less than half that projected by cadaveric data, indicating a protective effect of fluid in the injured state. The trends demonstrated by these simulations suggest that bony alignment and fluid in the ankle joint change loading patterns on the tibia and should be accounted for in future experiments.
Synovial fluid may play a protective role in ankle injuries, thus delaying the onset of arthritis. Reactive joint effusions may also function to additionally redistribute stresses with higher volumes of viscous fluid.
The interpretation of CT scans for the evaluation of calcaneal fractures is difficult. Three-dimensional (3D) reconstruction (volume rendering technique [VRT]) has been valuable in the evaluation of irregularly shaped bones. However, their value for the analysis of calcaneal fractures is still debated. Therefore, the objective of this study was to assess the effect of additional use of 3D CTs in calcaneal fractures.
In a prospective multicenter study, the CT data set of 5 different fractures was presented to 57 evaluators. First, the participating surgeons were asked to assess the fractures on the basis of axial, coronal, and sagittal reconstructions using a multiple-choice questionnaire. Second, 3D reconstructions (VRT) were presented. The CT scans were validated by the intraoperative findings and the results were compared to the model solution of 3 foot and ankle surgeons. Intra- and interrater reliabilities were calculated.
The proportion of intraobserver agreement was 82%, with Cohen kappa of = 0.748 (P < .001). Interrater agreement varied between 0.772 (P = .006) for the assessment of concomitant fractures and 0.987 (P < .001) for the suggested approach. The evaluation of several items improved after presentation of the 3D CTs (Cochrane Q test, P < .001). The benefit of 3D imaging was higher in inexperienced surgeons and complex fractures (Friedman test P < .001).
The evaluation of CT scans of calcaneal fractures was improved by the additional use of 3D images (VRT).
Level II, prospective comparative study.
Among the most important predictors of functional results of treatment of syndesmotic injuries is the accurate restoration of the syndesmotic space. The purpose of this study was to investigate the reduction performance of screw fixation and suture-button techniques using images obtained from computed tomography (CT) scans.
Patients at or below 65 years who were treated with screw or suture-button fixation for syndesmotic injuries accompanying ankle fractures between January 2012 and March 2015 were retrospectively reviewed in our regional trauma unit. A total of 52 patients were included in the present study. Fixation was performed with syndesmotic screws in 26 patients and suture-button fixation in 26 patients. The patients were divided into 2 groups according to the fixation methods. Postoperative CT scans were used for radiologic evaluation. Four parameters (anteroposterior reduction, rotational reduction, the cross-sectional syndesmotic area, and the distal tibiofibular volumes) were taken into consideration for the radiologic assessment. Functional evaluation of patients was done using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale at the final follow-up. The mean follow-up period was 16.7 ± 11.0 months, and the mean age was 44.1 ± 13.2.
There was a statistically significant decrease in the degree of fibular rotation (P = .03) and an increase in the upper syndesmotic area (P = .006) compared with the contralateral limb in the screw fixation group. In the suture-button fixation group, there was a statistically significant increase in the lower syndesmotic area (P = .02) and distal tibiofibular volumes (P = .04) compared with the contralateral limbs. The mean AOFAS scores were 88.4 ± 9.2 and 86.1 ± 14.0 in the suture-button fixation and screw fixation group, respectively. There was no statistically significant difference in the functional ankle joint scores between the groups.
Although the functional outcomes were similar, the restoration of the fibular rotation in the treatment of syndesmotic injuries by screw fixation was troublesome and the volume of the distal tibiofibular space increased with the suture-button fixation technique.
Level III, retrospective comparative study.
Although a ball and socket ankle deformity is usually congenital and asymptomatic, abnormal inversion and eversion mobility can result in recurrent ankle sprain and osteoarthritis. This retrospective study was performed to evaluate the clinical and radiologic outcomes of ankle fusion combined with calcaneal sliding osteotomy for severe arthritic ball and socket ankle deformity.
Fourteen patients with severe arthritic ball and socket ankle deformity were followed for more than 3 years after operation. The clinical evaluation consisted of American Orthopaedic Foot & Ankle Society (AOFAS) score, Foot and Ankle Ability Measure (FAAM), visual analog scale (VAS) for pain, and subjective satisfaction score. The period to fusion and union of osteotomy, the change of hindfoot alignment angle, and complications were evaluated radiologically.
AOFAS and FAAM scores were significantly improved from an average of 37.4 and 34.5 points to 74.6 and 78.5 points, respectively. VAS for pain with walking over 20 minutes was significantly improved from an average of 8.4 points to 1.9 points. The average satisfaction score of patients was 88.9 points. The difference in heel alignment angle (compared to contralateral side) was significantly improved from an average of 34.8 to 5.4 degrees. There were 2 cases of progressive arthritis in an adjacent joint and 1 case of failed fusion.
Ankle fusion combined with calcaneal sliding osteotomy can be an effective operative option for ball and socket ankle deformity with advanced arthritis. In spite of increased complication rate, reliable pain relief, and restoration of gait ability through correcting hindfoot malalignment could improve the quality of life.
Level IV, retrospective case series.
Although the tangential sesamoid view is used to visualize the sesamoid position relative to the first metatarsal head, correctly evaluating patients with severe varus of the first metatarsal is difficult. Computed tomography (CT) can be helpful due to its cross-sectional images in any plane. The purposes of this study were to evaluate the alignment of the tibial sesamoid and investigate the relationship between malalignment and degenerative change in the sesamoid metatarsal joint (SMJ) using simulated weight-bearing CT imaging in patients with hallux valgus.
In total, 269 feet from 142 patients with hallux valgus were included. The mean age was 63.7 years (range, 33-87 years). An anteroposterior weight-bearing radiograph was assessed for sesamoid position into 3 grades: grade 1, the tibial sesamoid was medial to the axis of the first metatarsal; grade 2, the tibial sesamoid was located below the first metatarsal axis; and grade 3, the tibial sesamoid was lateral to the first metatarsal axis. The hallux valgus and intermetatarsal angles (HVA and IMA, respectively) were measured. The lateral shift of the tibial sesamoid relative to the first metatarsal was classified into 3 grades on simulated weight-bearing CT classification: grade 1, tibial sesamoid was entirely medial to the intersesamoid ridge; grade 2, tibial sesamoid was subluxated laterally but located below the intersesamoid ridge; and grade 3, tibial sesamoid was located entirely lateral to the intersesamoid ridge. The differences of HVA and IMA in each grade were confirmed by using 1-way analysis of variance with Bonferroni post hoc corrections. Furthermore, multiple linear regression analysis was used to predict the degenerative change in the SMJ for age, sex, sesamoid position determined by CT or plain radiography, HVA, and IMA. The 2 test was used for descriptive statistics to analyze the agreement between radiography or CT classifications of sesamoid position against degenerative change in the SMJ.
Based on the radiographic classification of the tibial sesamoid position, 7 feet were classified as grade 1, 72 were grade 2, and 190 were grade 3, respectively. Based on the CT classification, 34 feet were classified as grade 1, 116 were grade 2, and 119 were grade 3. Degenerative change in SMJ progressed according to the sesamoid shift relative to the first metatarsal using either radiography or CT. In radiography, statistically significant differences were found except for the difference in HVA between grades 1 and 2. In addition, statistically significant differences were found between HVA and IMA, along with the grades in CT.
In multiple linear regression, degenerative change was correlated with age and sesamoid position in CT and radiographic classifications.
Our study showed that lateral shift of the tibial sesamoid increased in association with progression of the hallux valgus deformity. Furthermore, increasing lateral shift of the tibial sesamoid was associated with worsening degenerative change within the SMJ.
Level III, retrospective comparative study.
During hallux valgus surgery, the abnormal position of the first metatarsal bone relative to the sesamoids is addressed. Our study aimed to investigate the influence of postoperative tibial sesamoid position (TSP) on functional outcome and patient satisfaction after hallux valgus surgery.
Between February 2007 and November 2011, 250 patients who underwent hallux valgus surgery at our tertiary hospital were followed for 2 years after surgery. They were categorized into 2 groups based on Hardy and Clapham’s TSP classification, recorded on postoperative weight-bearing anteroposterior (AP) radiographs: (1) normal (grades I-IV) and (2) outliers (grades V-VII).
The mode TSP improved from grade VII preoperatively to grade IV postoperatively (P < .001). The visual analog scale for pain was 1 (95% CI 0, 1) point better in the normal group compared to the outlier group at 2 years after surgery (P = .050), whereas the American Orthopaedic Foot & Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale was 6 (95% CI 2, 11) points higher in the normal group (P = .009). Patients in the outlier group were also more likely to be dissatisfied with the surgery performed when compared to the normal group (OR 3.881, 95% CI 1.689, 8.920, P = .001).
We recommend correcting the TSP to grade of IV or less to improve functional outcome and satisfaction after hallux valgus surgery.
Level III, retrospective comparative series.
Venous thromboembolism (VTE) is a well-documented complication in patients with lower limb fractures, but management guidelines for its prevention in isolated foot and ankle fracture patients are conflicting. The aim of this study was to conduct a multicenter, prospective cohort study to define the prevalence of VTE in patients with isolated foot and ankle fractures and determine whether routine prophylaxis is necessary in these patients.
In a double-blind, placebo-controlled study, consecutive patients in 3 hospitals who met our criteria were enrolled. After randomization, patients received either thromboprophylaxis with low-molecular-weight heparin units (LMWH group) or placebo (placebo group) for a period of 2 weeks. All patients underwent routine ultrasonography 1 day preoperatively, 1 week postoperatively, and 1 month postoperatively. Demographic parameters were then collected and compared.
Of the 814 patients who met our criteria, 19 patients (2.3%, 95% confidence interval [CI], 0%-31.9%) were found to have objectively confirmed VTE, but none of the patients were symptomatic. Of the 411 patients in the LMWH group, 2 developed VTEs preoperatively and 4 postoperatively; of the 403 patients in the placebo group, 5 developed VTEs preoperatively and 8 postoperatively. The overall incidence of asymptomatic postoperative deep vein thrombosis (DVT) was 0.98% (95% CI 0%-20.3%) in the LMWH group and 2.01% (95% CI 0%-29.5%) in the placebo group without significant difference. Advanced age (odds ratio [OR] 1.050, 95% CI 1.014-1.088, P = .007) and high body mass index (OR 1.201, 95% CI 1.034-1.395, P = .016) were identified as risk factors in predicting occurrence of DVT. No fatal pulmonary emboli or major bleeding complication occurred in either group.
Routine anticoagulant prophylaxis was not found to be necessary for patients with foot and ankle fractures, although further investigation with a properly powered study design is required to definitively determine which foot and ankle patients are best served by anticoagulation and which ones are not.
Level II, prospective comparative study.
Functional limitations after lower extremity surgery often require the use of an assistive device for ambulation during rehabilitation and recovery. There are no known objective data evaluating the wheeled knee walker as an assistive device for protected ambulation. The purpose of this study was to compare assisted ambulation and perceived exertion with the wheeled knee walker and the axillary crutches in healthy participants.
A prospective, randomized crossover study was performed using 24 healthy volunteers. Each participant performed a 6-minute walk test (6MWT) using each assistive device in a crossover manner. Preactivity and postactivity heart rates were recorded. The self-selected walking velocity (SSWV) was calculated and the participant’s rating of perceived exertion was recorded using the OMNI Rating of Perceived Exertion (OMNI-RPE). Participant’s preference for assistive device was identified.
The 6MWT, SSWV, and the Omni-RPE were evaluated using paired t tests and determined to be statistically significant for the wheeled knee walker compared with axillary crutches. Evaluation of the preactivity and postactivity heart rates demonstrated a statistically significant difference for the wheeled knee walker compared with axillary crutches. The wheeled knee walker was preferred by 88% of participants.
The wheeled knee walker provided increased assisted ambulation and had a lower rating of perceived exertion than axillary crutches on level surfaces in healthy participants.
Level III, comparative study.
Fractures of the distal tibia, ankle, and foot sustained through a high-energy mechanism can be extremely debilitating, and ankle and/or subtalar fusion may be indicated if the limb is deemed salvageable. Functional outcomes among this population are often poor. The purposes of this study were to evaluate the effect of an advanced rehabilitation program combined with the use of a custom ankle-foot orthosis for patients with ankle or subtalar fusion on selected physical performance measures and patient-derived outcome measures and to determine if the response to treatment was predicated upon the type of fusion.
We conducted a prospective, longitudinal, observational, cohort study composed of 23 active duty Service Members treated for lower extremity trauma. Patients were separated into 2 groups: group 1 was composed of 12 patients who underwent isolated ankle fusion or ankle fusion combined with ipsilateral subtalar fusion, group 2 was composed of 11 patients who underwent subtalar fusion only. Patient-reported outcome (PRO) measures and physical performance measures were recorded at baseline and at the conclusion of the rehabilitation program.
Significant improvements in both groups were seen in each of the 4 physical performance measures. Only group 2 showed significant improvements in all domains of the Veteran’s Rand 12-Item Health Survey (VR-12) and Short Musculoskeletal Function Assessment (SMFA) at all points during the course of rehabilitation.
Among a subset of patients treated for severe lower extremity trauma with ankle and/or subtalar fusion, an integrated orthotic and rehabilitation initiative improved physical performance and PRO measures over an 8-week course.
Level III, prospective comparative series
Patients’ perception of outcomes is not always defined by the absence of limitations/symptoms (resolution), but can also be characterized by behavioral adaptation and cognitive coping arising in cases with residual deficits. Patient-reported outcome measures (PROs) are designed to measure levels of function or symptoms, largely missing whether patients are coping with ongoing limitations. This study aimed to broaden the conventional definition of a "satisfactory" outcome following ankle reconstruction by comparing patient-reported outcomes of patients with and without residual symptoms and limitations.
The study consisted of a cross-sectional survey of ankle arthroplasty (n = 85) and arthrodesis (n = 15) patients. Outcome measures included the Ankle Osteoarthritis Scale, Short Musculoskeletal Function Assessment, Short Form-12, and EuroQol-5 Dimension. Patients also completed measures of pain (0-10), stiffness (0-10), satisfaction (0-3), and ability to complete activities of daily living (ADL) (0-6). Based on a self-reported question regarding recovery and coping, patients were categorized as "Recovered-Resolved" (better with no symptoms or residual effects), "Recovered, not Resolved" (RNR, better with residual effects), or "Not Recovered" (not better). Recovery groups were compared across measures.
Only 15% of patients were categorized Recovered-Resolved. Most were RNR (69%), leaving 14% Not Resolved. Recovered-Resolved experienced lower rates of pain (1.4 ± 2.3), stiffness (1.1 ± 2.6), and difficulty performing ADLs (0.9 ± 1.2). Overall, outcome measure scores were high (ie, better health) for Recovered-Resolved patients, midrange for RNR patients, and low for Not Recovered patients, thus confirming predefined hypotheses. Recovered-Resolved and RNR patients had similarly high satisfaction summary scores (3.0 ± 0.0 vs 2.6 ± 0.6).
Most patients reported positive outcomes, but few (15%) experienced resolution of all symptoms and limitations. Current PROs focus on achieving low levels of symptoms and limitations, but miss an important achievement when patients are brought to a level of residual deficits with which they can cope. Patients’ perceptions of satisfactory outcomes were not predicated on the resolution of all limitations; thus, the conventional definition of "satisfactory" outcomes should be expanded accordingly.
Level II, prospective cohort study.
Longevity of total ankle replacement (TAR) depends heavily on anatomic alignment. The lateral talar station (LTS) classifies the sagittal position of the talus relative to the tibia. We hypothesized that correcting the sagittal distal tibial articular angle (sDTAA) during TAR would anatomically realign the tibiotalar joint and potentially reduce the risk of prosthesis subluxation.
The LTS (millimeters) and sDTAA (degrees) were measured twice by 2 blinded observers using weight-bearing lateral ankle radiographs obtained before (n = 96) and after (n = 94) TAR, with excellent interobserver and intraobserver reliability (correlation coefficient >0.9).
Preoperative LTS was as follows: anterior (60.4%), posterior (27.1%), and neutral (12.5%). A strong preoperative correlation was found between LTS and sDTAA (r = 0.81; P < .0001). In ankles that were initially anterior and became less anterior postoperatively (n = 41), LTS decreased from an average 8.1 mm to 6.5 mm and the LTS changed 1.1 mm per degree of sDTAA change. In ankles that were initially posterior (n = 25), LTS increased from an average of –5.1 mm to –2.8 mm and the LTS changed 0.6 mm per degree of sDTAA change. The correlation between LTS and sDTAA was reduced postoperatively (r = 0.62; P < .0001).
Our results suggest that rather than following generic recommendations, the surgeon should customize the sagittal distal tibial cut to the individual patient based on the preoperative LTS in order to achieve neutral TAR alignment.
Level III, retrospective comparative series.
Several studies report performing a recession of the gastrocnemius tendon as surgical treatment of foot and ankle pain related to an isolated gastrocnemius contracture. Few report ankle range of motion using a validated measurement device or report a control group. All previous studies reporting measurements using a validated device have been small in number.
Using a previously validated device, 66 patients presenting with foot or ankle pain and 66 controls were measured for ankle range of motion and isolated gastrocnemius contractures. Clinical and goniometer measurement of ankle range of motion was also performed.
The foot and ankle pain group had a mean dorsiflexion of 11.6 degrees compared with a mean of 17.2 degrees in the control group (P < .0001). No patients in either group had less than 15 degrees of motion with the knee flexed. The difference in dorsiflexion was less using a goniometer than using the validated device, which may be due to measurement technique and external landmarks.
Patients with foot and ankle pain had less ankle dorsiflexion than the control group. This is the largest study to date using a validated measurement device as well as a control group and supports the findings of previous authors.
Level II, prospective cohort study.
Despite increasing popularity of the Foot Function Index (FFI), normative values are still unavailable for this self-administered score. This study was designed to generate age- and sex-related normative values for the FFI-total and for both subscales FFI-pain and FFI-disability.
We used the cross-cultural adapted and validated German version of the FFI to generate a data pool using the results of 625 individuals, including staff and visitors to our hospital and excluding persons scheduled for foot surgery or in after-treatment.
Mean values for FFI-total were calculated: 15.3 points (95% confidence interval [CI], 13.3-16.9), 14.9 points for FFI-pain (CI, 13.3-16.5), and 15.6 for FFI-disability (CI, 13.8-17.4). Results showed higher values for FFI-total, FFI-pain, and FFI-disability for individuals older than 40 years. In general, normative values showed a tendency for higher values with age. A slightly inconsistent distribution over different age groups with a peak for individuals in their 40s and 50s was observed, especially for FFI-pain. Men had better scores than women. Individuals with previous surgery showed lower scores in their respective score.
Our data calculated normative values for a German-speaking cohort for FFI-total as well as for both subscales FFI-pain and FFI-disability. Our data quantified the increase of FFI-total, FFI-pain, and FFI-disability normative values with age but also showed a slightly inconsistent distribution of normative values over all age groups. We demonstrated higher normative values for women and slightly higher normative values for individuals with previous foot or ankle surgery.
II, prospective comparative study
Arthrodesis is a standard operative treatment for symptomatic arthritis of the first metatarsophalangeal (MTP) joint. Patients with degenerative joint disease (DJD), severe hallux valgus, and metatarsus primus varus may also require fusion of the first MTP joint. An important question in the latter group of patients is whether a proximal first metatarsal osteotomy is required, in addition to the first MTP joint fusion. Our hypothesis was that patients with severe hallux valgus and metatarsus primus varus, treated with first MTP joint arthrodesis alone, would have correction of the first-to-second intermetatarsal angle (1-2 IMA) and hallux valgus angle (HVA) to near population norms, without the addition of a proximal first metatarsal osteotomy.
Preoperative and postoperative radiographs of 19 feet, in 17 patients, with preoperative IMA greater than 15 were analyzed. Weight-bearing radiographs were divided into pre- and postoperative cohorts. Three independent reviewers measured these radiographs and mean 1-2 IMA and HVA were calculated. Mean follow-up was 10 months.
The mean preoperative 1-2 IMA was 19.2 degrees (15.6-24.3). The mean preoperative HVA was 48.5 (36-56.6). The mean postoperative values for 1-2 IMA and HVA were 10.8 and 12.3 degrees, respectively. The mean change in IMA was 8.3 degrees and in the hallux valgus angle was 36.4 degrees. The differences between pre- and postoperative measurement for both angles were statistically significant (P < .001). Seven of 19 (37%) feet were corrected to an IMA of less than 9 degrees (normal), whereas in 15/19 feet the postoperative IMA was 12.3 degrees or less. The postoperative HVA was less than 15 degrees in 15/19 (79%) feet.
This pre- and postoperative radiographic analysis of patients with severe bunion deformity demonstrated that HVA and 1-2 IMA were acceptably corrected without the addition of a proximal first metatarsal osteotomy.
Level III, retrospective comparative series.
The timing and strategy for operative treatment of flatfoot are still controversial. The purpose of this study was to evaluate clinical outcomes and radiographic changes following calcaneal Z osteotomy combined with subtalar arthroereisis for severe adolescent flexible flatfoot.
Data were analyzed for 16 patients (20 feet) who had flatfoot without tibialis posterior tendon dysfunction and were treated by calcaneal Z osteotomy combined with arthroereisis between October 2011 and February 2015. The mean age of patients at the time of surgery was 12.8 ± 1.4 years (range, 10-14 years). Preoperative and postoperative measurements included changes in hindfoot valgus angles; changes in talonavicular uncoverage angles on anteroposterior (AP) radiographic view; and changes in talo–first metatarsal angles, talar pitch angles, and calcaneal pitch angles on lateral radiographic view. The American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Score (AOFAS-AH) was used to assess foot function. The mean follow-up was 18.9 ± 6.9 months (range, 13-33 months).
The hindfoot valgus angle improved from 14.9 ± 4.2 degrees to 2.3 ± 1.7 degrees. On the AP view, the preoperative and postoperative talonavicular uncoverage angles were 30.5 ± 9.4 degrees and 9.8 ± 4.8 degrees, respectively. On lateral radiographs, the preoperative talo–first metatarsal angle, talar pitch angle, and calcaneal pitch angle were –22.1 ± 7.9 degrees, 36.1 ± 4.4 degrees, and 14.4 ± 4.0 degrees, respectively. Postoperative lateral radiographs demonstrated talo–first metatarsal angle, talar pitch angle, and calcaneal pitch angle of –6.2 ± 4.7 degrees, 27.3 ± 4.9 degrees, and 19.0 ± 4.3 degrees, respectively. The AOFAS-AH score improved from 66.8 ± 24.1 preoperatively to 96.5 ± 3.4 postoperatively.
For adolescents with flatfoot, calcaneal Z osteotomy combined with subtalar arthroereisis provided satisfactory results.
Level IV, retrospective case series.
Minimally invasive surgical (MIS) techniques are increasingly being used in foot and ankle surgery but it is important that they are adopted only once they have been shown to be equivalent or superior to open techniques. We believe that the main advantages of MIS are found in the early postoperative period, but in order to adopt it as a technique longer-term studies are required. The aim of this study was to compare the 2-year outcomes of a third-generation MIS distal chevron osteotomy with a comparable traditional open distal chevron osteotomy for mild-moderate hallux valgus. Our null hypothesis was that the 2 techniques would yield equivalent clinical and radiographic results at 2 years.
This was a retrospective cohort study. Eighty-one consecutive feet (49 MIS and 32 open distal chevron osteotomies) were followed up for a minimum 24 months (range 24-58). All patients were clinically assessed using the Manchester-Oxford Foot Questionnaire. Radiographic measures included hallux valgus angle, the intermetatarsal angle, hallux interphalangeal angle, metatarsal phalangeal joint angle, distal metatarsal articular angle, tibial sesamoid position, shape of the first metatarsal head, and plantar offset. Statistical analysis was done using Student t test or Wilcoxon rank-sum test for continuous data and Pearson chi-square test for categorical data.
Clinical and radiologic postoperative scores in all domains were substantially improved in both groups (P < .001), but there was no statistically significant difference in improvement of any domain between open and MIS groups (P > .05). There were no significant differences in complications between the 2 groups ( > .5).
The midterm results of this third-generation technique show that it was a safe procedure with good clinical outcomes and comparable to traditional open techniques for symptomatic mild-moderate hallux valgus.
Level III, retrospective comparative study.
Foot and ankle movement alterations following ankle arthrodesis are still not well understood, particularly those that might contribute to the documented increase in adjacent joint arthritis. Generalized tarsal hypermobility has long been postulated, but not confirmed in gait or functional movements. The purpose of this study was to more thoroughly evaluate compensation mechanisms used by arthrodesis patients during level and uphill gait through a variety of measurement modalities and a detailed breakdown of gait phases.
Level ground and uphill gait of 14 unilateral tibiotalar arthrodesis patients and 14 matched controls was analyzed using motion capture, force, and pressure measurements in conjunction with a kinetic multisegment foot model.
The affected limb exhibited several marked differences compared to the controls and to the unaffected limb. In loading response, ankle eversion was reduced but without a reduction in tibial rotation. During the second rocker, ankle dorsiflexion was reduced, yet was still considerable, suggesting compensatory talar articulation (subtalar and talonavicular) motion since no differences were seen at the midtarsal joint. Also during the second rocker, subjects abnormally internally rotated the tibia while moving their center of pressure laterally. Third rocker plantarflexion motion, moments, and powers were substantially reduced on the affected side and to a lesser extent on the unaffected side.
Sagittal plane hypermobility is probable during the second rocker in the talar articulations following tibiotalar fusion, but is unlikely in other midfoot joints. The normal coupling between frontal plane hindfoot motion and tibial rotation in early and mid stance was also clearly disrupted. These alterations reflect a complex compensatory movement pattern that undoubtedly affects the function of arthrodesis patients, likely alters the arthrokinematics of the talar joints (which may be a mechanism for arthritis development), and should be considered in future arthrodesis as well as arthroplasty research.
Level III, comparative study.
The aim of this study was to determine the outcome of delayed presentation (at least 6 weeks from the time of injury) of low-energy Lisfranc injuries limited to the first and second tarsometatarsal joints treated with open reduction internal fixation.
8 patients with an average age at surgery of 39.8 years were retrospectively reviewed with a mean time to surgery from injury of 15.1 (range of 6.3 to 31.1) weeks. We used radiographic measurements, physical examination, SF-12 scores, Foot and Ankle Ability Measure (FAAM) scores, VAS scores and return to work or sports as outcome measures. Patients were treated with an open reduction and internal fixation as opposed to a formal arthrodesis with a variety of internal fixation. All 8 patients were available for follow-up and outcome reporting at an average of 3.1 years (minimum 2.0) postoperatively.
The mean VAS improved from 8.5 to 2.8 postoperatively. The mean postoperative physical and mental SF-12 scores were 46.8 and 57.1, respectively. The mean postoperative overall and sports FAAM scores were 75.4 and 65.9, respectively. There were no radiographic signs of a late diastasis at the Lisfranc joint. All patients including 2 workers compensation cases returned to work and all were able to return to their prior sporting activity.
A delayed open reduction internal fixation of patients with missed, low-energy Lisfranc injury was performed and resulted in decreased pain. In this series, a fair to good functional outcome was observed, and the ability to return to work or previous sport was possible for all patients studied.
Level IV, retrospective case series.
The purposes of this study were to compare the quality of life (QOL) of subjects who had untreated symptomatic hallux valgus with the QOL of the general population and to investigate factors associated with the QOL of the subjects.
One hundred sixteen subjects with previously untreated and symptomatic hallux valgus were surveyed. QOL was assessed using the 36-item Short Form Health Survey (SF-36). Additionally, clinical evaluations (the visual analog scale for pain, Japanese Society for Surgery of the Foot Scale, lesser toe pain, and pain in other parts of the body) and radiographic evaluations (hallux valgus angle, intermetatarsal angle between the first and second metatarsals, and dislocation of the second metatarsophalangeal joint) were performed. Differences in the SF-36 between the subjects and the general population were tested using independent t tests. Correlations between the QOL measurements, clinical evaluations, and radiographic evaluations were assessed using Spearman rank correlation coefficient.
All SF-36 subscales and physical component summary scores for the subjects were significantly lower than those of the general population. Notably, the standardized physical function subscale (38.2 ± 15.8, P < .001) and physical component summary scores (38.9 ± 14.5, P < .001) were more than 10 points lower than those of the general population. Most QOL and clinical evaluation parameters were not correlated or were negligibly correlated with radiographic evaluations. Similarly, lesser toe pain or pain in other parts of the body was not correlated with QOL or clinical evaluations.
The QOL of untreated and symptomatic hallux valgus subjects was lower than that of the general population. All QOL and clinical evaluation parameters were not significantly or negligibly correlated with the severity of toe deformities. Surgical decision making should not be based on the severity of the deformity alone, but rather patient QOL should also be carefully assessed.
Level III, comparative series.
Tobacco use is a known risk factor for increased perioperative complications and having worse functional outcomes in many orthopedic procedures. To date, no study has elucidated the effect of cigarette smoking on complications or functional outcome scores after total ankle replacement (TAR).
We retrospectively reviewed the records of 642 patients who had TAR between June 2007 and February 2014 with a known smoking status. These patients were separated into 3 groups based on their smoking status: 34 current smokers, 249 former smokers, and 359 nonsmokers. Outcome scores and perioperative complications, which included infection, wound complications, revision surgeries, and nonrevision surgeries were compared between the groups.
When comparing perioperative complications in the active smokers to the nonsmokers, we found a statistically significant increased risk of wound breakdown (hazard ratio [HR] 3.08, P = .047). Although the active smokers had an increased rate of infection (HR 2.61, P = .392), revision surgery (HR 1.75, P = .470), and nonrevision surgery (HR 1.69, P = .172), these findings were not statistically significant. With regard to outcome scores, all groups demonstrated improvement at 1- and 2-year follow-up compared with their preoperative outcome scores. However, the active smokers had less improvement in their outcome scores than the nonsmokers at 1- and 2-year follow-up. Furthermore, there was no significant difference in the outcome scores when comparing the nonsmokers to the former smokers.
Active cigarette smokers undergoing TAR had a significantly higher risk of wound complications and worse outcome scores compared with nonsmokers and former smokers. Furthermore, tobacco cessation appeared to reverse the effects of smoking, which allowed TAR to be an effective and safe procedure for providing pain relief and improving function in former smokers as they had perioperative complication rates and outcomes similar to nonsmokers.
Level III, retrospective comparative series.
Lateralizing calcaneal osteotomy (LCO) is a frequently used technique to correct hindfoot varus deformity. Tibial nerve palsy following this osteotomy has been described in case reports but the incidence has not been quantified.
Eighty feet in 72 patients with cavovarus foot deformity were treated over a 6-year span by 2 surgeons at their respective institutions. Variations of the LCO were employed for correction per surgeon choice. A retrospective chart review analyzed osteotomy type, osteotomy location, amount of translation, and addition of a tarsal tunnel release in relation to the presence of any postoperative tibial nerve palsy. Tibial nerve branches affected and the time to resolution of any deficits was also noted.
The incidence of neurologic deficit following LCO was 34%. With an average follow-up of 19 months, a majority (59%) resolved fully at an average of 3 months. There was a correlation between the development of neurologic deficit and the location of the osteotomy in the middle third as compared to the posterior third of the calcaneal tuber. We found no relationship between the osteotomy type, amount of correction, or addition of a tarsal tunnel release and the incidence of neurologic injury.
Tibial nerve palsy was not uncommon following LCO. Despite the fact that deficits were found to be transient, physicians should be more aware of this potential problem and counsel patients accordingly. To decrease the risk of this complication, we advocate extra caution when performing the osteotomy in the middle one-third of the calcaneal tuberosity. Although intuitively the addition of a tarsal tunnel release may protect against injury, no protective effect was demonstrated in this retrospective study.
Level III, retrospective cohort study.
Localized nerve pain in the foot and ankle can be a chronic source of disability after trauma and has been identified as the most common complication following operative interventions in the foot and ankle. The superficial location of the injured nerves and lack of suitable tissue for nerve implantation make this pain refractory to conventional methods of neuroma management. We describe a novel strategy for management using processed nerve allografts to bridge nerve gaps created by resection of both end neuromas and neuromas-in-continuity.
A retrospective review of a prospectively maintained database was performed of all patients who received a processed nerve allograft for treatment of painful neuromas in the foot and ankle between May 2010 and June 2015. Patient demographic and operative information was obtained, as well as preoperative and postoperative pain assessments using a conventional ordinal scale and PROMIS (Patient Reported Outcomes Measurement Information System) Pain Behavior and Pain Interference assessments. Twenty-two patients were identified, with postoperative pain assessments occurring at a mean of 15.5 months after surgery.
Neuromas of the sural and superficial peroneal nerves were the most common diagnoses, with 3-cm nerve allografts being used as the interposition graft in the majority of cases. Eight patients had end neuromas and 18 patients had neuromas in continuity. Analysis of paired data demonstrated a mean ordinal pain score decrease of 2.6, with 24 and 31 percentage-point decreases in PROMIS Pain Behavior and Pain Interference measures, respectively. All changes were significant (P < .002).
The painful sequelae of superficial nerve injuries in the foot and ankle was significantly improved with complete excision of the involved nerve segment followed by bridging of the resulting nerve gap with a processed nerve allograft. This approach limits surgery to the site of injury and reconstitutes the peripheral nerve anatomy.
Level IV, retrospective case series.
Large cystic osteochondral defects of the talus can be challenging to treat. This retrospective control study looked at the use of osteochondral autograft transfer combined with cancellous allograft in patients with advanced cartilage and subchondral bone damage of the talus.
Thirteen patients were treated with large cystic osteochondral defect of the talus between February 2010 and July 2013. All of these cystic osteochondral defects were larger than 15 mm in diameter. The subchondral defects were filled with cancellous allograft and the center of the lesions were sealed with an osteochondral cylinder autograft that was harvested from the ipsilateral medial femoral condyle. The visual analog scale (VAS) score for pain during daily activities, American Orthopaedic Foot & Ankle Society Ankle and Hindfoot (AOFAS-AH) scores and subjective satisfaction survey rating were obtained. Plain radiographs and magnetic resonance imaging of the ankle were obtained before and after surgery. In 5 cases, arthroscopy was performed 12 months postoperatively, and the cartilage repair was assessed with the criteria of the International Cartilage Repair Society. Twelve patients were available for follow-up at a mean of 25.4 months (range, 18 to 48 months).
Average postoperative AOFAS-AH score 12 months after surgery was 88±7 compared with 64±10 preoperatively. The mean VAS score decreased from 6±1 preoperatively to 1±1 at the latest follow-up. Seven patients rated their result as excellent, 5 as good and none as fair. The radiolucent area of the cysts disappeared on the plain radiographs in all cases. The mean International Cartilage Repair Society arthroscopic score from follow-up arthroscopy was 9±1 points.
The use of osteochondral autograft transfer combined with cancellous allograft was an effective option for the treatment of large cystic talar osteochondral lesions.
Level IV, retrospective case series.
Screws placed from posterior to anterior have been shown to be biomechanically and anatomically superior in the fixation of talar neck and neck-body fractures, yet most surgeons continue to place screws from an anterior start point. The safety and efficacy of percutaneously applied posterior screws has not been clinically defined, and functional outcomes after their use is lacking.
After institutional review board approval, we performed a retrospective review of 24 consecutive talar neck fractures treated by a single surgeon that utilized posterior-to-anterior screw fixation. Clinical, radiographic, and functional outcomes were assessed at a minimum follow-up of 12 months. Functional outcomes including the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, Olerud-Molander Scores, and the Short Form 36 (SF-36) measurement were collected and reviewed. Average patient follow-up was 44 months.
According to the classification system of Canale and Kelly, there were 4 type I fractures, 15 type II fractures, 4 type III fractures, and 1 type IV fracture. Four patients had open fractures. One superficial wound infection occurred, 1 patient reported FHL stiffness, and 6 complained of numbness or paresthesias in the distribution of the sural nerve (5 transient, 1 permanent). One reoperation was required to exchange a screw impinging on the talonavicular joint. Radiographically, 44% developed a positive Hawkins sign, and the specificity of this finding was 100% for talar dome viability. Avascular necrosis developed in 43% of patients, with 33% revascularizing and none going on to collapse. Subtalar arthrosis developed in 62% of patients.
Screws placed from posterior to anterior are a useful technique in the treatment of talar neck fractures. Functional outcomes following their use appear favorable compared with recent reports with minimal risk to local structures.
Level IV, retrospective case series.
Although more than 1500 publications on hallux valgus can be found in the current literature, none of them have reported on the course of pain resolution after hallux valgus surgery. Thus, this study aimed to investigate pain resolution after hallux valgus surgery and to identify predictive factors associated with residual pain at 6 months after surgery.
We prospectively followed up 308 patients who underwent hallux valgus surgery at a tertiary hospital at 6 months and 2 years after surgery. Multivariate logistic regression analysis was performed to evaluate the risk factors associated with residual pain after surgery.
Ninety-four patients (31%) had some degree of residual pain at 6 months after surgery. After excluding 4 patients who developed osteoarthritis of the first metatarsophalangeal joint over the next 18 months, 73 of the remaining 90 (81%) experienced improvement in visual analog scale (VAS) by the 2-years follow-up. Their median VAS improved from 4 (interquartile range [IQR] 3, 5) at 6 months to 0 (IQR 0, 3) at 2 years (P < .001). A higher preoperative VAS increased the risk of having persistent pain at 6 months after sugery (odds ratio [OR] 1.388, 95% confidence interval [CI] 1.092, 1.764, P = .007), whereas a higher preoperative Mental Component Score of SF-36 (MCS) reduced this risk (OR 0.952, 95% CI 0.919, 0.987, P = .007).
As much as 31% of patients will have residual pain at 6 months after surgery. Preoperative VAS and MCS are predictors for residual pain. However, these patients will continue to improve over the next 18 months, with 71% of them being pain free at 2 years after surgery.
Level II, prospective comparative study.
The purpose of this study was to examine factors associated with pain after elective ankle and hindfoot reconstruction.
Patients who underwent major ankle or hindfoot reconstruction over a 3-year period were identified. Retrospective chart review determined patient demographics, comorbidities, surgeries, tobacco, alcohol, and narcotic use, chronic pain, and mood disorders. Primary outcomes were cumulative amount of narcotic prescribed (morphine milligram equivalent dose) in the initial 90-day postoperative period, beyond 90 days, and visual analog pain score (VAS) at a minimum of 1-year follow-up. One hundred thirty-two patients (139 operations) met the inclusion criteria.
The average narcotic amount prescribed in the initial 90 days after surgery was 1711 mg (morphine equivalent), and narcotic prescriptions were required after 52 surgeries (35%) past 90 days. Preoperative narcotic use (P < .01), chronic pain disorder (P = .02), and mood disorder (P < .01) were significant risk factors for continued narcotic use past 90 days. Tobacco use (P = .01) and chronic pain disorder (P < .01) also were significant risk factors for increased initial postoperative narcotic use. The average VAS score in 91 patients at an average of 2.7-year follow-up was 2.1. Mood disorder was a risk factor for increased VAS (P < .01). No other associations were noted.
Patients being treated for chronic pain, diagnosed with a mood disorder, taking any amount of narcotics preoperatively, or using tobacco products had a statistically significant increased risk for pain postoperatively. The presence of risk factors should prompt physicians to discuss pain management strategies before surgery.
Level III, comparative series.
Electromagnetic bone growth stimulators have been found to biologically enhance the bone healing environment, with upregulation of numerous growth factors. The purpose of the study was to quantify the effect, in vivo, of pulsed electromagnetic fields (PEMFs) on growth factor expression and healing time in fifth metatarsal nonunions.
This was a prospective, randomized, double-blind trial of patients, cared for by 2 fellowship-trained orthopedic foot and ankle surgeons. Inclusion criteria consisted of patients between 18 and 75 years old who had been diagnosed with a fifth metatarsal delayed or nonunion, with no progressive signs of healing for a minimum of 3 months. Eight patients met inclusion criteria and were randomized to receive either an active stimulation or placebo PEMF device. Each patient then underwent an open biopsy of the fracture site and was fitted with the appropriate PEMF device. The biopsy was analyzed for messenger-ribonucleic acid (mRNA) levels using quantitative competitive reverse transcription polymerase chain reaction (QT-RT-PCR). Three weeks later, the patient underwent repeat biopsy and open reduction and internal fixation of the nonunion site. The patients were followed at 2- to 4-week intervals with serial radiographs and were graded by the number of cortices of healing.
All fractures healed, with an average time to complete radiographic union of 14.7 weeks and 8.9 weeks for the inactive and active PEMF groups, respectively. A significant increase in placental growth factor (PIGF) level was found after active PEMF treatment (P = .043). Other factors trended higher following active PEMF including brain-derived neurotrophic factor (BDNF), bone morphogenetic protein (BMP) -7, and BMP-5.
The adjunctive use of PEMF for fifth metatarsal fracture nonunions produced a significant increase in local placental growth factor. PEMF also produced trends toward higher levels of multiple other factors and faster average time to radiographic union compared to unstimulated controls.
Level I, prospective randomized trial.
Surgeons disagree about the safety of adding adjuvant procedures requiring separate incisions during total ankle replacement (TAR). This study tested the hypothesis that complication rates for patients in the first year after TAR would be greater when combined with procedures through separate incisions.
A retrospective review was performed on a consecutive series of 124 patients who underwent total ankle replacement between 2007 and 2013. Demographics, case-specific data, and postoperative complications over the first year were collected. A chi-square analysis was performed to compare differences in complication rates among patients with and without additional procedures requiring a separate incision. The average patient age was 67±10 years. Fourteen patients (11%) were diabetic and 2 patients (2%) were current smokers. Eighty-seven (70%) had prior trauma leading to arthritis. Ninety-seven (78%) cases used the Scandinavian Total Ankle Replacement (STAR), 16 (13%) Salto Talaris, and 11 (9%) In Bone implants. Ten (8%) cases were revisions. Excluding percutaneous Achilles lengthening, 35 of 124 patients (28%) had a total of 54 adjuvant procedures requiring a separate incision during TAR. These included 9 (7%) calcaneal osteotomies, 8 (6%) medial malleolar fixation, 6 (5%) subtalar fusions, 5 (4%) lateral ligament repair, 4 (3%) open Achilles lengthening, 4 (3%) removal of hardware, 2 (2%) first metatarsal osteotomy, and 8 other procedures.
Overall, 32 (26%) of the 124 patients had a complication, including 15 (12%) delayed wound healing, 6 (5%) malleolar fracture, and 11 other complications. At 1 year, 24 (27%) of 89 patients without additional incisions and 8 (23%) of 35 patients with additional incisions, excluding percutaneous Achilles lengthening, had any complication (P = .64).
This study did not demonstrate an association between additional procedures requiring a separate incision during TAR and early complications. Overall complication rates were similar to previously reported series of TAR. This study suggests that surgeons can add adjuvant procedures during TAR to improve alignment, stability, or treat adjacent segment arthritis without affecting short-term complication rates. The necessity or utility of these adjuvant procedures requires further study.
Level III, comparative series.
Intra-articular calcaneus fractures result in heel shortening, widening, varus malalignment, and loss of height. Little has been written regarding superior displacement of the calcaneal tuber, which warrants consideration as previous literature has demonstrated issues arising from a shortened triceps surae. We sought to determine the amount of tuber elevation seen in calcaneus fractures as compared to normal calcanei and propose 2 new measurements that aid in quantifying displacement and may aid in the surgical management of calcaneus fractures.
Lateral radiographs of 220 normal calcanei were examined. Two novel measurements, the talo-tuber angle and talo-tuber distance, were used to establish normative data for calcaneal tuber positioning. Lateral radiographs of 50 calcaneus fractures treated operatively were examined and the same measurements were obtained before and after surgery to determine the amount of superior tuber elevation.
Normative data demonstrated a mean of 38.6 degrees (±SD = 4.3, range: 26.2-58.4) when using the talo-tuber angle and 54.5 mm (±SD = 7.3, range: 36.2-72.6) when using the talo-tuber distance in normal calcanei. Patients sustaining calcaneus fractures demonstrated a mean of 29.5 degrees (±SD = 5.9, range: 20-46.4) for the talo-tuber angle and 39.0 mm (±SD = 9.4, range: 24.0-62.9) for the talo-tuber distance. These values changed to a mean of 37 degrees (±SD = 5.2, range: 26.4-50) for the talo-tuber angle and 51.8 mm (±SD = 8.6, range: 33.2-75.7) for the talo-tuber distance after surgery. There was a statistically significant difference (P value < .01) for both talo-tuber angle and distance between normal and fractured calcanei. Inter- and intra-observer agreement was excellent.
Superior displacement of the calcaneal tuber is a deformity seen in intra-articular calcaneus fractures that has been poorly described that warrants increased awareness and correction at the time of surgery. We propose 2 novel measurements with associated normative data that may aid surgeons in quantifying this deformity and assessing anatomic reduction.
Level III, comparative study.
Tarsal tunnel syndrome is a known complication of lateralizing calcaneal osteotomy. A Malerba Z-type osteotomy may preserve more tarsal tunnel volume (TTV) and decrease risk of neurovascular injury. We investigated 2 effects on the tarsal tunnel of the Malerba osteotomy compared to a standard lateralizing osteotomy using a cadaveric model: (1) the effect on TTV as measured by magnetic resonance imaging (MRI) and (2) the proximity of the osteotomy saw cuts to the tibial nerve.
Ten above-knee paired cadaveric specimens underwent MRI of the ankle to obtain a baseline measurement of TTV. One foot in each pair received a standard lateralizing calcaneal osteotomy, with the other foot receiving a Malerba osteotomy. MRIs were performed after each of 3 increasing amounts of lateral displacement, which were accompanied by increasing amounts of wedge resection in the Malerba osteotomy group. TTV was measured on MRI using previously described and validated parameters. Differences in TTV with osteotomy type, displacement, and their interaction were assessed with generalized estimating equations. After all MRIs were completed, each specimen was dissected and the nearest distance of tibial nerve branches to the osteotomy site was measured.
Baseline TTV averaged 13 229 ± 2354 mm3 and did not differ between groups (P = .386). TTV decreased on average by 7% after the first translation, 14% after the second, and 27% after the third (P < .005 for each). The magnitude of the decrease in TTV did not differ between those specimens with standard osteotomies versus those with Malerba osteotomies (P = .578). At least one of the major branches of the tibial nerve crossed the osteotomy site in 5 of 5 specimens that received the Malerba osteotomy versus 2 of 5 that received a standard osteotomy.
Regardless of osteotomy type, lateralizing calcaneal osteotomy decreased TTV. In all specimens, the osteotomy was at the level of branches of the tibial nerve.
Our results demonstrate that lateralizing calcaneal osteotomies must be performed with care to avoid excessive lateral translation as well as direct nerve injury on the nonvisualized medial side of the calcaneus.
Gastrocnemius shortening causes an equinus deformity that may clinically manifest in foot disorders, including metatarsalgia. We use this term to describe pain localized to the metatarsal heads. The purposes of this prospective study were to review the effect of medial gastrocnemius proximal release on ankle dorsiflexion and assess the outcome of this technique on pain and functional limitations in patients who have mechanical metatarsalgia and isolated gastrocnemius shortening.
We prospectively followed a consecutive series of 78 feet in 52 patients with metatarsalgia who had an isolated gastrocnemius contracture assessed with the Silfverskiöld test. Surgical release was evaluated with visual analog scale (VAS) and American Orthopaedic Foot & Ankle Society (AOFAS) scales. Ankle dorsiflexion was measured at 1, 3, and 6 months postoperatively.
Preoperative values of VAS and AOFAS were 7.4 and 46.8, respectively. After 3 months postoperatively, the values were 3.0 and 81.7, and 6 months after surgery these values were 3.5 and 83.6. No patient worsened clinically. There were no major complications. Thirty-six patients (69.2%) were completely satisfied with the results of the surgery. Preoperatively, ankle dorsiflexion with the knee straight was –17.5 degrees, which improved to 2.5 degrees at 6 months postoperatively.
We believe proximal medial gastrocnemius recession is an alternate procedure to treat selected patients with mechanical metatarsalgia and gastrocnemius shortening. It had acceptable morbidity and cosmetic results.
Level IV, case series.
Topical agents have been shown to be effective in soft tissue injuries and commonly used in outpatient clinics. However, the data regarding topical agents in the emergency department is insufficient, and they are not used often in the emergency department setting. The present study aimed to compare the effect of 2.5% topical ketoprofen (gel form) to placebo in patients presenting with ankle sprain to the emergency department.
Patients presenting with ankle sprain composed the study population. Study patients were randomized into 2 study arms: 2.5% ketoprofen gel and placebo administered over a 5-cm area locally. Pain alleviation was measured by visual analog scale at 15 and 30 minutes. A total of 100 patients were included in the final analysis.
The median pain reduction in ketoprofen and placebo groups at 15 minutes was 27 (19.8-33.4) and 9 (7.6-17), respectively. The median pain reduction at 30 minutes for both groups was 42 (36-50.8) and 20 (17.6-24.4), respectively. Pain improvement either at 15 minutes (median difference: 16 [9-22]) or 30 minutes (median difference: 21 [15-27]) was better in the ketoprofen group than placebo. There were no adverse effects in either group.
Ketoprofen gel was superior to placebo at 30 minutes in alleviating pain secondary to ankle sprain in the ED with a high safety profile. Further studies are needed concerning the effect of ketoprofen gel for long-term effects.
Level I, high quality prospective randomized study.
The aim of this prospective study was to evaluate the influence of sectioning the calcaneofibular ligament (CFL) during an extensile lateral approach during open reduction and internal fixation (ORIF) of calcaneal fractures on ankle joint stability.
Forty-two patients with calcaneal fractures that received ORIF were included. Talar tilt stress and anterior drawer radiographs were performed on the operative and contralateral ankles 6 months postoperatively.
The average degree of talar tilt on stress radiographs was 3.4 degrees (range, 0-12 degrees) on the operative side and 3.2 degrees (range, 0-14 degrees) on the contralateral side. The mean anterior drawer on stress radiographs of the CFL incised ankle was 6.1 mm (range, 2.4-11.8 mm) and on the contralateral ankle was 5.7 mm (range, 2.6-8.6 mm). There was no statistically significant difference of talar tilt and anterior drawer between the CFL incised side and the contralateral side (P = .658 and .302, respectively).
The results suggest that sectioning of the CFL without any repair during ORIF of a calcaneal fracture does not have a negative effect on stability of the ankle. Repair of the CFL is, thus, probably not necessary following extended lateral approach for ORIF of calcaneal fractures.
Level II, comparative study.
Supramalleolar osteotomy (SMOT) is an alternative operative procedure for the management of early and midstage varus ankle arthritis. However, whether fibular osteotomy is needed is controversial. The purpose of the current study was to evaluate the functional and radiologic outcomes of pre- and postoperative SMOT, and to compare the outcomes between patients with and without fibular osteotomy.
Forty-one Takakura stage 2 and 3 varus ankle osteoarthritis patients treated with SMOT were included. Fourteen males and 27 females with a mean age of 50.7 (range, 32-71) years were followed with a mean of 36.6 (range, 17-61) months. There were 22 cases with fibular osteotomy and 19 without. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, Maryland foot score, and Ankle Osteoarthritis Score (AOS) were used for pre- and postoperative functional evaluation. The tibial articular surface angle (TAS), talar tilt (TT), tibiocrural angle (TC), and tibial lateral surface angle (TLS) were evaluated pre- and postoperatively.
At the last follow-up, the mean AOFAS score (from 50.8 to 83.1 points) and Maryland score (from 58.3 to 81.6 points) in overall were improved (P < .01); the mean AOS pain (from 42.6 to 26.1 points) and function (from 53.4 to 36.8 points) scores were decreased (P < .01). For radiologic evaluation, all the included parameters were improved (P < .05) except TLS. The mean Takakura stage was decreased (P < .01). No significant difference could be detected in comparing the functional outcomes between those with and without fibular osteotomy. However, in the fibular osteotomy group, TT was decreased (P < .05) and TC was improved (P < .01) significantly.
SMOT was promising, with substantial functional improvement and malalignment correction for varus ankle arthritis. Fibular osteotomy may be necessary in cases with large TT and small TC angles.
Level III, retrospective comparative study.
The intraoperative assessment of the articular surface in displaced intra-articular distal tibia fractures can be challenging using conventional fluoroscopy. The aim of the study was to determine the frequency and the method of intraoperative corrections of fracture reductions or implant placements during open reduction, internal fixation by using cone beam computed tomography (CT) after conventional fluoroscopy.
Displaced intra-articular distal tibia fractures were retrospectively analyzed from August 2001 until December 2011. The fractures were classified according to the standards of the AO/OTA as type B or C and treated with open reduction and internal plate fixation. After primary reduction using conventional fluoroscopy, an additional cone beam CT scan was used to determine the alignment of the joint line and the implant position. The number of intraoperative revisions of the primary reduction due to the use of cone beam CT was analyzed.
A total of 143 patients with an intra-articular tibial plafond fracture were included in the analysis. In 43 patients (30%), an intraoperative correction was performed after the cone beam CT scan. In 34 (24%) of these cases, intraoperative correction was required because of inadequate joint line reduction. Nine (6%) corrections were required as a result of a malposition of the implant. The revision rate did not differ by fracture classification.
Despite its acceptance as the standard method of imaging, intraoperative conventional fluoroscopy for the assessment of implant positioning and fracture reduction of tibial plafond fractures is limited. The intraoperative utilization of cone beam CT provided additional information for the surgeon to detect insufficient reduction or implant malposition.
Level III, retrospective comparative series.
The lateral extensile incision for fixation of displaced intra-articular calcaneus fractures allows for fracture reduction but has been associated with high rates of soft tissue complications. This has prompted a search for less invasive methods of fracture fixation. The purpose of the present study was to determine the adequacy of reduction and rate of complications associated with operative fixation of calcaneal fractures using a limited sinus tarsi approach.
A limited sinus tarsi incision with plate fixation was utilized for treatment of 39 displaced intra-articular calcaneal fractures in 35 consecutive patients as part of a single surgeon series. Imaging assessment of previously described fracture displacement measures was undertaken in preoperative and postoperative radiographs and CT. A retrospective chart review was conducted to identify postoperative complications.
Mean preoperative Bohler angle measurement was 7.7 (range, –26.0 to 30.0) degrees and the mean final postoperative standing Bohler angle was 25.5 (range, 12.3 to 37.7) degrees. Postoperative CT demonstrated that subtalar articular reduction was within 2 mm of anatomic in 91% of patients. There were 2 instances of superficial wound dehiscence (5.1%) and 1 deep infection (2.6%) that required debridement and complete hardware removal. Visual analog score (VAS) for pain averaged 3 of 10 in the 32 available patients at 1-year follow-up. Eight of these patients (25%) reported no pain (0/10) at final follow-up.
Operative fixation of displaced intra-articular calcaneal fractures utilizing the limited sinus tarsi approach resulted in acceptable fracture reduction and a low rate of complications.
Level IV, retrospective case series.
Autologous osteochondral transplantation (AOT) has an inherent risk of donor site morbidity (DSM). The reported rates of DSM vary from 0% to 50%, with few studies reporting clinical or imaging outcomes at the donor site as a primary outcome and even fewer report these outcomes when a biosynthetic plug backfill is employed. Although TruFit (Smith & Nephew, Andover, MA) plugs have been removed from the market for regulatory purposes, biphasic plugs (including TruFit plugs) have been used for several years and the evaluation of these is therefore pertinent.
Thirty-nine patients who underwent forty AOT procedures of the talus, with the donor graft being taken from the ipsilateral knee, were included. Postoperative magnetic resonance imaging (MRI) was used to assess the donor site graded with magnetic resonance observation of cartilage repair tissue (MOCART) scoring. Lysholm scores were collected preoperatively, at the time of magnetic resonance imaging (MRI), and again at 24 months and at final follow-up to assess clinical outcomes. Statistical analysis was performed to establish if there was any correlation between MRI assessment of the donor site and clinical outcomes. The mean patient age was 36.2 ± 15.7 years with a mean follow-up of 41.8 ± 16.7 months.
All patient donor site defects were filled with OBI TruFit biphasic plugs. DSM was encountered in 12.5% of the patient cohort at 24 months, and in these patients, the Lysholm score was a mean 87.2 ± 5.0. At final follow-up, DSM was reduced to 5%. Lysholm scores for the entire cohort were 98.4 ± 4.6 and 99.4 ± 3.1 at 24 months and final follow-up, respectively. MRI of the donor sites were taken at an average of 18.1 ± 13.5 (range, 3-48) months postoperatively and the mean MOCART score was 60.0 ± 13.5. No correlation was found between the MOCART score and Lysholm outcomes at the donor knee (P = .43, r = 0.13).
Low incidence of DSM and good functional outcomes were achieved with AOT. Additionally, MRI findings did not predict clinical outcomes in our study.
Level IV, retrospective case series.
This study classified plantar heel spurs and their relationship to plantar fasciitis.
Patients included those with plantar fasciitis who were treated from 2012 through 2013. Plantar heel spur shape and size were assessed radiographically and correlated to function and pain before and after treatment. Function and pain were scored with the Foot and Ankle Ability Measures and a visual analog scale, respectively. This study included 109 patients with plantar fasciitis.
The plantar heel spur shape was classified as 0/absent in 26 patients, 1/horizontal in 66 patients, 2/vertical in 4 patients, and 3/hooked in 13 patients. The plantar heel spur size was less than 5 mm in 75 patients, 5-10 mm in 28 patients, and greater than 10 mm in 6 patients. Initially, patients with any shape or size to their spur had no difference in function and pain. With treatment, patients with horizontal and hooked spurs had the greatest improvement in function and pain (P < .05). With treatment, patients with larger spurs had the greatest improvement in function and pain (P < .05).
Plantar heel spurs can be classified by shape and size in patients with plantar fasciitis. Before treatment, neither the spur shape nor size significantly correlated with symptoms. After treatment, patients with larger horizontal or hooked spurs had the greatest improvement in function and pain. These findings may be important when educating patients about the role of heel spurs with plantar fasciitis and the effect of nonsurgical treatment with certain spurs.
Level III, comparative series.
Determining the stability of ankle fractures, particularly Weber B fibula fractures, can be challenging. Ability to weight-bear after injury may be predictive of stability. We sought to determine whether patients’ ability to weight-bear immediately after injury was an effective indicator for ankle stability following fracture.
A prospective review was conducted of patients sustaining ankle fractures. Patients’ ability to weight-bear after injury was elicited and correlated with ankle radiographs, which were deemed stable or unstable based on commonly used indices to assess stability.
For the entire cohort (n = 121), patients who were able to weight-bear immediately after injury were over 8 times more likely to have a stable fracture than those who could not (odds ratio [OR] = 8.6, P < .001). Positive predictive value (PPV) for being able to fully weight-bear as it related to stability was 73%. Inability to weight-bear was 85% specific among patients with an unstable fracture. When analyzing patients with radiographic isolated fibula fractures (n = 67), PPV = 82%, negative predictive value [NPV] = 53%, specificity = 79%, whereas the OR was 5.0 (P = .003) for those who could weight-bear having a stable fracture. When subanalyzing patients who presented with isolated fibula fractures and anatomic mortises (n = 43), PPV = 74%, NPV = 52%, specificity = 62%, whereas the OR was 3.6 (P = .07) for those who could weight-bear having a stable fracture.
Patients’ ability to weight-bear immediately after injury was a specific and prognostic indicator for stability across a range of ankle fracture subtypes. Patients with an isolated fibula fracture and anatomic mortise were 3.6 times more likely to have a stable fracture if they were able to fully weight-bear at the time of injury. Although a patient’s history does not preclude the need for appropriate imaging studies and clinical judgment, it may aid in the assessment of ankle stability following fracture.
Level II, clinical diagnostic.
This study presents patient-reported outcomes and patient satisfaction data for the largest series of US patients undergoing modern fixed-bearing total ankle arthroplasty (TAA).
We retrospectively reviewed the records of 300 consecutive patients who underwent 321 modern, fixed-bearing TAAs at a single institution. Veterans Rand 12-Item Health Survey (VR-12), Ankle Osteoarthritis Scale (AOS), and the American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot score were collected preoperatively and at subsequent follow-up appointments. A patient satisfaction survey was also distributed to each patient postoperatively. Of the 321 TAAs, 245 (232 patients) had a minimum of 2-year follow-up and a complete data set. Furthermore, 192 patients underwent concomitant procedures. The average follow-up was 38.9 months (24-84.5). Eight patients have been lost to follow-up (7 deceased and 1 refused further follow-up).
The mean AOFAS score preoperatively was 41.1 and at latest follow-up was 84.6 (P < .01). The mean VR-12 score was 29.7 (Physical) and 54.1 (Mental) preoperatively and 42.7 (Physical) and 55.7 (Mental) at latest follow-up (P < .01 and P > .05, respectively). AOS pain and disability scores improved significantly after TAA (P < .01). The patient satisfaction survey indicated that 84% experienced very good to excellent pain relief, 78% reported improved ability to perform daily tasks, and 54% indicated improvement in their ability to perform heavy work or recreational activities. In addition, 94% would probably or definitely have the procedure on the contralateral ankle. Two patients underwent revision TAA at a minimum of 36 months; 8 patients failed the primary TAA and were converted to ankle fusions at a mean of 20.1 months (6.1-46.1).
Early results of a large series of a modern TAA system demonstrate improvement in patient satisfaction, quality of life, activity, and pain for patients with end-stage ankle arthritis. Early revision was due to infection or loosening of the tibial component.
Level IV, case series.
Habitual use of high-heeled shoes (HHS) has been reported to negatively impact different body structures. However, few studies have investigated its effect on plantarflexor performance. The aim of this study was to investigate the effect of habitual wear of HHS and knee joint position (to isolate the function of the gastrocnemius) on the isokinetic performance of the plantarflexors and ankle joint range of motion (ROM).
A high-heel (HH) group included 12 women (25.4 ± 4.8 y) who have been wearing HHS for ≥40 hours/wk and for at least a year. A control group (CTRL) had 12 women (21.3 ± 0.5 y) who have occasionally been wearing HHS for <10 hours/wk. Participants performed isokinetic (60 degrees/s) plantarflexion movements through a range set between 15 degrees dorsiflexion and 30 degrees plantarflexion. Ankle joint ROM and average peak plantarflexion torque and power were recorded in 2 knee joint positions, extension and 90 degrees flexion.
Overall, torque was significantly affected by knee position (P = .04) and habitual use of HHS (P < .001), whereas power was impacted by knee position only (P < .001). Within each group, flexing the knee reduced isokinetic measurements. However, the reduction was greater for the HH group (torque: 54 Nm, power: 35.6 W) compared with the CTRL group (torque: 42 Nm, power: 32.5 W). Ankle joint ROM was significantly different between groups in knee flexion only.
Flexing the knee limited the plantarflexor muscular performance and the limitation was more significant in habitual users of HHS compared to nonusers. Thus, it is concluded that habitual use of HHS impacts the contractile properties of soleus more than gastrocnemius.
The soleus is important for walking and anterior cruciate ligament protection. Thus, HHS users could be susceptible to injury and may need longer and more intensive posttraumatic rehabilitation. Therefore, clinicians should consider knee position when examining the plantarflexors of habitual HHS users.
Charcot osteoarthropathy (COA) is characterized by a progressive destruction of bone and joint associated with neuropathy and is most common in the foot and ankle. Clinical manifestation of COA is frequently indistinguishable from other causes of pain, swelling, and erythema of the affected extremity, in particular, infection. Diagnosis of COA can be challenging in particular in early stages where radiographic changes are sparse. The presence of elevated systemic inflammatory parameters in the context of suspected infection may delay early diagnosis and treatment of COA. The aim of this retrospective analysis was to assess whether elevated systemic inflammatory parameters may be present, in particular in early stages of COA and thus not be used as an exclusion criterion for the diagnosis of COA.
Forty-two patients (mean age 48.2 ± 9.4 years, 36 male, 6 female) with a diagnosis of unilateral COA were the subject of this retrospective study. The diagnosis of COA was confirmed by plain radiographs, magnetic resonance imaging and clinical course. Systemic inflammatory parameters were recorded at the time of referral. Acute stages (stages 0 and 1) were treated with a total contact cast (TCC) and protected weight bearing for a minimum of 6 weeks. For chronic stages (stages 2 and 3) custom-made shoes were prescribed. The feet were stratified into "acute" (Eichenholz stages 0 and 1) and "subacute/chronic" (Eichenholz stages 2 and 3) groups.
Statistically significant differences were observed for all recorded systemic inflammatory parameters (C-reactive protein level, WBC count, erythrocyte sedimentation rate) between the acute and subacute/chronic groups. No statistical difference was observed considering the anatomic pattern of involvement.
The present study demonstrated that elevated systemic inflammatory parameters may be present in COA and can further be used to distinguish between acute and subacute stages of COA, based on the Eichenholtz classification. Thus, we suggest that elevated inflammatory markers should not be considered an exclusion criterion for the diagnosis of COA.
Level III, retrospective comparative series.
Underlying bony deformity may be related to development of adult-acquired flatfoot deformity (AAFD). Multiplanar weightbearing (MP-WB) computed tomography can be used to identify subtalar deformity which may contribute to valgus hindfoot alignment. On coronal MP-WB images, 2 angles reliably evaluate the subtalar joint axis: the angle between the inferior facet of the talus and the horizontal (inftal-hor) and the angle between the inferior and superior facets of the talus (inftal-suptal). Although these angles have been shown to differ significantly between flatfoot patients and controls, no study has investigated their relationships with other components of AAFD. We hypothesized that these angles would correlate strongly with commonly used radiographic measures of AAFD.
Forty-five patients with stage II AAFD and 17 control patients underwent MP-WB imaging and standard weightbearing radiographs. MP-WB measurements were correlated with standard radiographic measurements of AAFD. Differences between AAFD and control patients were assessed using independent samples t tests and Mann-Whitney U tests. To assess correlations between each MP-WB measurement and radiographic measurement, factorial generalized linear models (GLMs) were constructed.
Patients with AAFD differed from the controls in all measured angles (P ≤ .001 for each). After accounting for differences between flatfoot and control patients, inftal-hor was not significantly correlated with any of the radiographic angles. Inftal-suptal, however, correlated with the AP coverage angle, AP talar–first metatarsal angle, calcaneal pitch, Meary’s angle, medial column height, and hindfoot alignment after accounting for differences between flatfoot patients and controls. Meary’s angle alone explained 48% of the variation in inftal-suptal angles.
As measured on coronal MP-WB images, patients with stage II AAFD had more innate valgus in their talar anatomy as well as more valgus alignment of their subtalar joints than did control patients. It is possible that this information could be used to identify patients likely to have progression of deformity and may ultimately guide the approach to operative reconstruction.
Level III, case-control study.
Depression, anxiety, and stress are prevalent in patients with musculoskeletal pain, but the impact of these emotional states has not been evaluated in people with plantar heel pain. The aim of this study was to evaluate the association between depression, anxiety, and stress with plantar heel pain.
Forty-five participants with plantar heel pain were matched by sex and age (±2 years) to 45 participants without plantar heel pain. Levels of depression, anxiety, and stress were measured using the Depression, Anxiety and Stress Scale (short version) in participants with and without plantar heel pain. Logistic regression was conducted to determine if levels of depression, anxiety, or stress were associated with having plantar heel pain.
Univariate analysis indicated that participants with plantar heel pain had greater levels of depression (mean difference = 4.4, 95% CI 2.3 to 6.5), anxiety (mean difference = 2.6, 95% CI 0.9 to 4.3), and stress (mean difference = 4.8, 95% CI 1.9 to 7.8). After adjusting for age, sex, BMI, and education, for every 1 unit increase in depression, anxiety, or stress (in the DASS subscales), the odds ratios for having plantar heel pain were increased by 1.3 (95% CI 1.1 to 1.6), 1.3 (95% CI 1.1 to 1.5), and 1.2 (95% CI 1.1 to 1.3), respectively.
Symptoms of depression, anxiety, and stress were independently associated with plantar heel pain. Larger prospective studies are necessary to evaluate the temporal association between these emotional states and plantar heel pain.
Level III, cross sectional, observational.
Osteochondral lesions (OCLs) associated with ankle fracture correlate with unfavorable outcome. The goals of this study were to detect OCLs following ankle fracture, to associate fracture type to OCLs and to investigate whether OCLs affect clinical outcome.
100 ankle fractures requiring operative treatment were prospectively included (46 men, 54 women; mean age 44 ± 14 years, range 20-77). All ankle fractures (conventional radiography; 71 Weber B, 22 Weber C, 1 Weber A, 4 isolated medial malleolus and 2 isolated posterior malleolus fractures) were treated by open reduction and internal fixation. Multidetector computed tomography (CT) was performed postoperatively. For each OCL, the location, size, and Loomer OCL classification (CT modified Berndt and Harty classification) were determined. The subjective Foot and Ankle Outcome Scoring (FAOS) was used for clinical outcome at 1 year.
OCLs were found in 10/100 ankle fractures (10.0%). All OCLs were solitary talar lesions. Four OCLs were located posteromedial, 4 posterolateral, 1 anterolateral, and 1 anteromedial. There were 2 type I OCLs (subchondral compression), 6 type II OCLs (partial, nondisplaced fracture) and 2 type IV OCLs (displaced fracture). Mean OCL size (largest diameter) was 4.4 ± 1.7 mm (range, 1.7 mm to 6.2 mm). Chi-square analysis showed no significant association between ankle fracture type and occurrence of OCLs. OCLs did occur only in Lauge-Hansen stage III/IV ankle fractures. There were no significant differences in FAOS outcome between patients with or without OCLs.
Ten percent of investigated ankle fractures had associated OCLs on CT. Although no significant association between fracture type and OCL was found, OCLs only occurred in Lauge-Hansen stage III/IV ankle fractures. With the numbers available, OCLs did not significantly affect clinical outcome at 1 year according to FAOS.
Level IV, observational study.
Total range of motion between the tibia and the floor is an important outcome measure following ankle surgery. However, there is wide variation in its measurement: from clinical evaluation, to radiographic metrics, and gait analysis. The purpose of this study was to present and validate a simple, standardized technique for measurement of functional total range of motion between the tibia and the floor using a digital goniometer.
Institutional review board approval was obtained. Forty-six ankles from 33 participants were recruited into 2 groups: Group 1 (healthy controls) comprised 20 ankles from 10 participants. None had any musculoskeletal or neurologic pathology. Group 2 (ankle osteoarthritis) comprised 25 ankles from 23 patients. Ankle pathology had been treated with ankle arthrodesis (n = 5), total ankle replacement (n = 6), and nonoperative treatment (n = 14). Measurement was performed by 2 testers according to a standardized protocol developed for the Total Ankle Replacement Versus Arthrodesis (TARVA) randomized controlled trial. Intra- and interrater reliability was calculated using intraclass correlation coefficients (ICCs).
Group 1 (healthy controls): the median difference for all measurements within an observer was 1.5 (interquartile range [IQR] 0.7-2.5) degrees, and the intraclass coefficients (ICCs) for inter- and intrarater total ankle range of motion were excellent: 0.95 (95% confidence interval [CI] 0.91-0.97, P < .001) and 0.942 (95% CI 0.859-0.977, P < .001), respectively. Group 2 (ankle osteoarthritis): the median difference for all measurements within an observer was 0.6 (IQR 0.2-1.3) degrees, and the ICCs for inter- and intrarater total ankle range of motion were excellent: 0.99 (95% CI 0.97-1.0), P < .001) and 0.99 (95% CI 0.96-1.0), P < .001), respectively.
This technique provided a reliable, standardized method for measurement of total functional range of motion between the tibia and the floor. The technique required no special equipment or training. It provided a valid functional assessment for patients with or without ankle osteoarthritis, including those who had undergone operative treatment.
Level II, prospective comparative study.
The increased popularity and success of total ankle arthroplasty (TAA) has resulted in the development of varying TAA hardware designs, many of which include specific bone-sparing or bone-sacrificing features. The goal of this work was to determine differences in the volume of bone removed for implantation of different total ankle arthroplasty hardware systems.
Sixteen cadaveric specimens were computed tomography–scanned preoperatively and after total ankle arthroplasty using either an INBONE II, Salto Talaris, STAR, or Zimmer TMTA implant. Geometries of the talus and the distal tibia were manually segmented and converted to 3D bony surface models. The volume of bone removed for each implant was calculated as the difference in volume between the preoperative and postoperative bone models. To account for differences in specimen size, volume was expressed as a percentage of the intact bone.
There was a significant difference (P = .049) in the average percent of talar bone removed, with the STAR and INBONE II systems requiring removal of greater volumes of bone. The INBONE II system required significantly (P < .004) more tibial bone resection than the other 3 implants when evaluating a long span of the distal tibia. However, most of this increased bone resection was medullary bone. Close to the articular surface, bone volumes removed for the various tibial components were not significantly different (P = .056).
Volume and location of bone removed for different implant systems varied with implant design.
Primary bone resection associated with different implant hardware systems varied more on the talar side of the articulation, and the stemmed prosthesis did not result in dramatic increases in periarticular bone resection. Clinicians should weigh the effects of greater or lesser bone resection associated with various implant designs against other factors used for hardware selection.
A new transfibular total ankle arthroplasty (TAA) system has not been assessed for potential early complications.
We retrospectively assessed prospectively collected data on the initial cohort of patients undergoing TAA with this implant. We evaluated visual analog scale (VAS) pain and function, range of motion, and early radiographic outcomes.
Twenty consecutive TAAs (19 patients) were treated with the implant from January 2013 through June 2014. Average patient age was 63.7 (range, 41-80) years, with an average follow-up of 18 (range, 12-27) months. No fibular nonunion or implant failure was found at 12 months postoperatively. One patient had asymptomatic mild tibial lucency. Four of 20 TAAs underwent additional surgery for anterior impingement (1 ankle), deep infection and symptomatic fibular hardware (1 ankle), and symptomatic fibular hardware (2 ankles).
Of 20 ankles treated with a new transfibular arthroplasty system, no fibular nonunion, delayed union, or implant failure was noted at 12 months postoperatively. Two complications were resolved with secondary treatment, and 2 other ankles underwent secondary surgery for symptomatic fibular hardware with good outcome. The findings suggest that this total ankle system is safe and effective at short-term follow-up.
Level IV, retrospective case series.
Hindfoot deformity has been described as a risk factor for poor hallux valgus (HV) surgery outcomes. However, there has been no study that demonstrates it. The purpose of this investigation was to evaluate the influence of hindfoot misalignment in HV surgery results.
All patients operated on for HV during 2010 and 2011 at 3 university hospitals were included. The preoperative and 2-year postoperative radiologic data included the HV and the intermetatarsal (IM) angles, the naviculocuboid overlap (NC), the talonavicular coverage (TN) angle, the talus–first metatarsal (T-1MT) angle, as well as the calcaneal pitch (CP) angle. Additionally, the Short Form–36 questionnaire version 2.0 (SF-36) and the American Orthopaedic Foot & Ankle Society (AOFAS) score, satisfaction and recurrence were also analyzed. A total of 207 met the inclusion criteria. There were 26 patients (12.6%) who could not be assessed at the 2-year follow-up. Patients were allocated to a varus, normal, or a valgus hindfoot tertile using the values for the CP, NC, TN, and T-1MT angles.
No significant differences (P > .05) were found between the groups when the HV or IM angles, AOFAS, SF-36 Mental Composite Scale, SF-36 Physical Composite Scale, or satisfaction were compared. Similarly, no significant and strong correlations were observed (P > .05, < 0.3) between any of the mentioned hindfoot measures and the outcomes scales.
No influence of hindfoot misalignment on HV surgery outcomes was found in the present study in terms of correction, pain, function, satisfaction, or quality of life. Patients with hindfoot misalignment did not obtain worse outcomes in HV surgery.
Level II, prognostic, comparative study.
Symptomatic accessory navicular syndrome (ANS) typically develops in young athletes. The symptoms are exacerbated during exercise or while walking, affecting the sports performance of athletes. The purpose of this study was to evaluate the radiologic findings and clinical course in athletes with accessory navicular syndrome (ANS) in comparison with a nonathletic population.
Seventy-nine patients with ANS between August 2012 and August 2013 were included. Overall, 29 were athletes and 50 were not athletes, and 19 (2 athletes and 17 nonathletes) of them improved after at least 6 months of conservative treatment. The records of 60 patients (64 consecutive feet) of ANS treated by modified Kidner operation were evaluated retrospectively. The study population included 27 athletes (31 feet) and 33 nonathletes (33 feet). Clinical features and radiologic findings were compared between them.
Overall, 34% of the nonathletes improved after conservative treatment, but only 6.9% of athletes improved (P < .001). Mean age at surgery in the athlete group was 16.1 years (range, 12-26), and 24.3 years (range, 12-52) in the nonathlete group (P < .001). There was a history of trauma in 23 feet (74%) of the athlete group and in 13 feet (39%) of the nonathlete group (P = .006). Eighteen feet (58%) in the athlete group and 11 feet (32%) in the nonathlete group showed movement between the 2 bones (P = .047). Bone marrow edema was observed in both navicular and accessory navicular in all of the athletes (27/27, 100%). But it was only present in 80% (16/20) for nonathletes (P = .012).
The radiologic findings and clinical course of athletes were different from that of the general population. Their symptoms were more refractory to conservative treatment than the nonathletes group. Therefore, early operative treatment could be considered in cases of symptomatic ANS especially for athletes.
Level III, retrospective comparative case series.
Normal biomechanics of the ankle joint includes sagittal as well as axial rotation. Current understanding of mobile-bearing motion at the tibial-polyethylene interface in total ankle arthroplasty (TAA) is limited to anterior-posterior (AP) motion of the polyethylene component. The purpose of our study was to define the motion of the polyethylene component in relation to the tibial component in a mobile-bearing TAA in both the sagittal and axial planes in postoperative patients.
Patients who were a minimum of 12 months postoperative from a third-generation mobile-bearing TAA were identified. AP images were saved at maximum internal and external rotation, and the lateral images were saved in maximum plantarflexion and dorsiflexion. Sagittal range of motion and AP translation of the polyethylene component were measured from the lateral images. Axial rotation was determined by measuring the relative position of the 2 wires within the polyethylene component on AP internal and external rotation imaging. This relationship was compared to a table developed from fluoroscopic images taken at standardized degrees of axial rotation of a nonimplanted polyethylene with the associated length relationship of the 2 imbedded wires. Sixteen patients were included in this investigation, 9 (56%) were male and average age was 68 (range, 49-80) years. Time from surgery averaged 25 (range, 12-38) months.
Total sagittal range of motion averaged 23±9 (range, 9-33) degrees. Axial motion for total internal and external rotation of the polyethylene component on the tibial component averaged 6±5 (range, 0-18) degrees. AP translation of the polyethylene component relative to the tibial component averaged 1±1 (range, 0-3) mm. There was no relationship between axial rotation or AP translation of the polyethylene component and ankle joint range of motion (P > .05).
To our knowledge, this is the first investigation to measure axial and sagittal motion of the polyethylene component at the tibial implant interface in patients following a mobile-bearing TAA. Based on outcome scores and range-of-motion measurements, we believe the patients in this study are a representative cross section of subjects compared to other TAA research results. The results from this investigation indicate the potential for a mobile-bearing TAA to fall within the parameters of normal polyaxial ankle motion. The multiplanar articulation in a mobile-bearing TAA may reduce excessively high peak pressures during the complex dynamic tibial and talar motion, which may have a positive influence on gait pattern, polyethylene wear, and implant longevity.
Level IV, case series.
Despite its efficacy in healing neuropathic diabetic foot ulcers (DFUs), total contact cast (TCC) is often underused because of technical limitations and poor patient acceptance. We compared TCC to irremovable and removable commercially available walking boots for DFU offloading.
We prospectively studied 60 patients with DFUs, randomly assigned to 3 different offloading modalities: TCC (group A), walking boot rendered irremovable (i-RWD; group B), and removable walking boot (RWD; group C). Patients were followed up weekly for 90 days or up to complete re-epithelization; ulcer survival, healing time, and ulcer size reduction (USR) were considered for efficacy, whereas number of adverse events was considered for safety. Patients’ acceptance and costs were also evaluated.
Mean healing time in the 3 groups did not differ (P = .5579), and survival analysis showed no difference between the groups (logrank test P = .8270). USR from baseline to the end of follow-up was significant (P < .01) in all groups without differences between the groups. Seven patients in group A (35%), 2 in group B (10%), and 1 in group C (5%) (Fisher exact test P = .0436 group A vs group C) reported nonsevere adverse events. Patients’ acceptance and costs were significantly better in group C (P < .05).
Our results suggest that a walking boot was as effective and safe as TCC in offloading the neuropathic DFUs, irrespective of removability. The better acceptability and lesser costs of a removable device may actually extend the possibilities of providing adequate offloading.
Level II, prospective comparative study.
First metatarsophalangeal (MTP) joint arthrodesis is a common procedure for treatment of arthritis of the first MTP joint. The primary aim of this study was to evaluate the functional outcomes of a series of patients of multiple surgeons undergoing first MTP joint arthrodesis, emphasizing the functional gains with respect to daily activity that can be expected after this procedure.
A retrospective review of 53 patients who underwent successful isolated first MTP joint arthrodesis with either a plate and screw or independent screw construct was performed at our institution over a 6-year period. Successful fusion was defined as no lucency at the first MTP joint and bridging of 2 or more cortices on the anteroposterior, lateral, and oblique radiographic views at final follow-up. Demographic information and radiographs were evaluated for all patients. Preoperative and postoperative Foot and Ankle Outcome Score (FAOS) and Short Form Health Status Survey (SF) 36/12 functional outcome scores, as well as responses from an activity- and footwear-specific questionnaire, were evaluated and compared between the 2 fixation methods. Fifty-three patients (56 feet) had radiographs showing successful fusions after being treated for advanced degenerative arthritis of the first MTP joint with arthrodesis. Average time to union was 5.4 months.
There was a significant reduction in difficulty in performing daily activities, with all subscales of the FAOS and the SF-12v2 significantly improving postoperatively (P < .05). The majority of patients stated that their foot looked and felt better and were satisfied with the procedure. Five patients experienced painful hardware, which required removal.
First MTP joint arthrodesis was successful in improving patient-reported outcomes, particularly the ability to perform daily activities. Most patients had little to no functional limitation and were satisfied with their outcome. The greatest functional improvements were seen in patients’ ability to walk distances and perform low-impact sport activity.
Level III, retrospective comparative study.
Unstable ankle fractures with syndesmotic injuries commonly occur and can result in significant morbidity. Although the need for an anatomic reduction is clear, there is still debate surrounding the optimal operative treatment. Recent literature shows an increasing interest in anatomic ligament repair or reconstruction in the acute and chronic syndesmosis injury. Despite this trend, there is insufficient literature detailing anatomy of the distal tibiofibular syndesmosis. In the literature that does exist, there is controversy regarding the ligamentous anatomy of the syndesmosis. None of the current literature describes an anatomic constant that may be used as an intraoperative reference for anatomic ligament reconstructions.
Ten sets of tibia and fibula free of all soft tissue were used to analyze osseous structures. Another 10 nonpaired, fresh-frozen specimens were used to study the distal tibiofibular syndesmosis. These were measured using a 3-dimensional tracking system. Measurement of each ligament width at origin and insertion, length, and distance from the tibial articular cartilage was performed.
The superior and inferior insertions of the anterior inferior tibiofibular ligament measured 22.7 mm and 3.4 mm proximal to the distal articular cartilage of the tibia, respectively. The superior insertion of the posterior inferior tibiofibular ligament measured 15.2 mm proximal to the articular cartilage. The superior and inferior insertions of the interosseous ligament measured 31.8 mm and 9.2 mm proximal to the distal articular cartilage, respectively. The inferior transverse ligament was a prominent identifiable structure in 70% of specimens.
The superior margin of the distal articular cartilage could serve as a consistent anatomic landmark for reconstruction. The inferior transverse ligament is an identifiable structure in 70% of the specimens studied.
This article clarifies the anatomy and provides measurements from an anatomic constant that can guide reconstruction and intraoperative evaluation of the syndesmosis.
Open reduction and internal fixation with a plate is deemed to represent the gold standard of surgical treatment for displaced intra-articular calcaneal fractures. Standard plate fixation is usually placed through an extended lateral approach with high risk for wound complications. Minimally invasive techniques might avoid wound complications but provide limited construct stability. Therefore, 2 different types of locking nails were developed to allow for minimally invasive technique with sufficient stability. The aim of this study was to quantify primary stability of minimally invasive calcaneal interlocking nail systems in comparison to a variable-angle interlocking plate.
After quantitative CT analysis, a standardized Sanders type IIB fracture model was created in 21 fresh-frozen cadavers. For osteosynthesis, 2 different interlocking nail systems (C-Nail; Medin, Nov. Město n. Moravě, Czech Republic; Calcanail; FH Orthopedics SAS; Heimsbrunn, France) as well as a polyaxial interlocking plate (Rimbus; Intercus GmbH; Rudolstadt, Germany) were used. Biomechanical testing consisted of a dynamic load sequence (preload 20 N, 1000 N up to 2500 N, stepwise increase of 100 N every 100 cycles, 0.5 mm/s) and a load to failure sequence (max. load 5000 N, 0.5 mm/s). Interfragmentary movement was detected via a 3-D optical measurement system. Boehler angle was measured after osteosynthesis and after failure occurred.
No significant difference regarding load to failure, stiffness, Boehler angle, or interfragmentary motion was found between the different fixation systems. A significant difference was found with the dynamic failure testing sequence where 87.5% of the Calcanail implants failed in contrast to 14% of the C-Nail group (P < .01) and 66% of the Rimbus plate. The highest load to failure was observed for the C-Nail. Boehler angle showed physiologic range with all implants before and after the biomechanical tests.
Both minimally invasive interlocking nail systems displayed a high primary stability that was not inferior to an interlocking plate.
Based on our results, both interlocking nails appear to represent a viable option for treating displaced intra-articular calcaneal fractures.
Recently, as total ankle arthroplasty (TAA) has been widely performed, its outcomes and complications have been reported. Heterotopic ossification (HO) after TAA has been reported in the posterior compartment of the ankle. We report on a series of HOs that developed in the anterior compartment of the ankle at the talar neck region after TAA.
TAA was performed using the Hintegra and the Mobility in 54 ankles (Hintegra, 21 ankles; Mobility, 33 ankles) from 2004 to 2012. The outcome was assessed by visual analog scale (VAS), the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, patient satisfaction, and radiographic evaluation. The HO was confirmed on the lateral ankle view. HO in the anterior compartment of the ankle was classified based on a modification of the Brooker classification.
After TAA, 13 HOs developed in 12 of the 54 ankles. Six HOs developed in the anterior compartment, and 7 HOs developed in the posterior compartment. The majority of the anterior compartment HO (5/6) was observed in the Mobility group. There was no significant relationship between HO and the clinical outcomes (VAS score, P = .62; AOFAS score, P = .31; ankle range of motion, P = .31).
Besides the posterior ankle, the anterior compartment of the ankle in the talar neck region was demonstrated to be another potential area for HO after TAA. The development of anterior HO was strongly related to the wide exposure of the cancellous bony surface at the talar neck and therefore occurred more often with the Mobility than with the Hintegra prosthesis.
Level III, retrospective comparative case series.
Total ankle arthroplasty (TAA) has become a successful treatment for end-stage ankle arthritis. Some patients may still have pain or may present with new pain. Suggested sources of medial pain include tibialis posterior tendonitis, impingement, or medial malleolar stress fracture. Etiology and treatment remain unclear. The objective of our study was to evaluate patients with delayed-onset medial malleolar pain following TAA who underwent treatment with percutaneous medial malleolar screw placement and propose an etiology.
Patients who had undergone TAA at our institution were reviewed and those with medial malleolar pain were identified. Clinical and radiographic examinations were performed pre- and postoperatively. Radiographs were compared with those from a cohort of controls without a history of medial pain. All affected patients failed conservative therapy and were treated with percutaneous placement of medial malleolar screws positioned from the malleolar tip and extending proximally beyond the tibial component. Postoperatively, patients were placed in an ace wrap and allowed to be weightbearing to tolerance, except for 1 patient initially restricted to partial weightbearing. Visual analog scale (VAS) scores were recorded. Seventy-four (74) patients underwent TAA by the corresponding author. All (100%) were female with an average age of 66 (range, 57-73) years. Average follow-up since screw placement was 21.4 (range, 10-41) months.
Six (8.1%) underwent placement of 2 percutaneous medial malleolar screws. Patients presented with pain an average of 12 (range, 4-24) months postoperatively and underwent screw placement an average of 2.8 (range, 1-6) months after presentation. At the time of TAA, none had a coronal plane deformity and none underwent a deltoid ligament release as part of balancing. All (100%) patients had pain and swelling directly over the medial malleolus prior to screw placement. Postoperatively, 1 (17%) had mild pain clinically at this site and 2 (33%) had occasional pain medially with activity. Average VAS scores improved from 5.7 (range, 4-6) preoperatively to 1.3 (range, 0-3) postoperatively (P < .05). Three (50%) patients had a bone density test and all were normal. Prior to screw placement, radiographs demonstrated no signs of stress fracture or misalignment. Average minimum width of the medial malleolus at the level of the tibial component was 10.2 mm (range, 9.2-11.0), which was significantly less (P < .05) than the control group of 19 patients whose distance measured 12.2 mm (range, 8.5-14.8).
Patients who present with new-onset medial malleolar pain with normal radiographs following TAA may have medial malleolar insufficiency fracture. These patients can be treated successfully with minimal morbidity by placement of percutaneous medial malleolar screws. Etiology may be related to deltoid traction, subacute stress fracture, and/or impingement of the talus component on the medial malleolus. Medial malleolar pain may be misdiagnosed as tibialis posterior tendonitis, impingement, or implant failure. This diagnosis should be considered in patients who have pain at the medial malleolus, particularly if they are female or have medial malleolus thickness less than 11 mm at the level of the tibial implant. Placement of prophylactic medial malleolar screws may be considered at the time of TAA when these conditions exist.
Level IV, case series.
While it is thought that stresses through the subtalar and talonavicular joints will be decreased after total ankle replacement (TAR) relative to ankle fusion, progressive arthritis or deformity of these joints may require a fusion after a successful TAR. However, after ankle replacement, it is unknown how hindfoot biomechanics and blood supply may be affected. Consequently, subsequent hindfoot joint fusion may be adversely affected.
We retrospectively identified a consecutive series of 1001 primary TARs performed between January 1998 and December 2014. We identified patients who underwent a secondary triple, subtalar or talonavicular arthrodesis to treat progressive arthritis or pes planus deformity. Clinical outcomes including pain and functional outcome scores, revision procedures, delayed union, nonunion, complications, and failure rates were recorded. Twenty-six patients (2.6%) required a subtalar (18), talonavicular (3), talonavicular and subtalar (3), or triple arthrodesis (2). Of these patients, 14 (54%) were males with an average age of 63.2 years and a mean 70.9 months follow-up. We then compared these patients to 13 patients who had a subtalar fusion after an ankle arthrodesis.
The most common type of fixation used was 2 variable-pitch screws across each joint. Fresh-frozen allograft cancellous chips were the most common supplement to the fusion construct (80.8%). The mean time between TAR and secondary fusion procedure was 37.5 months. Overall, 92.3% of the patients went on to fusion. Two patients (7.7%) had a delayed union and 2 patients had a nonunion (7.7%) and were considered operative failures. There were 3 repeat procedures related to the arthrodesis procedure: 1 conversion of a subtalar to a triple arthrodesis, 1 revision talonavicular fusion, and 1 revision subtalar fusion. The average time to weight bearing after arthrodesis was 8.7 weeks; the mean time to radiographic and clinical fusion was 26.5 weeks. There were no secondary complications associated with the arthrodesis. Pain and functional outcome scores improved significantly. There were no differences in the rates of subsequent fusions among implant choices, though the time to fusion in the mobile-bearing prosthesis was significantly longer than the 2 fixed-bearing prostheses. Compared with the data of 13 patients with prior ipsilateral ankle arthrodeses and subtalar fusions, patients who had an ankle replacement had a higher fusion rate (P = .03) and had a similar time to fusion.
Hindfoot arthrodesis following a TAR was safe and effective in improving function and pain. Additionally, a hindfoot arthrodesis following a TAR had a higher fusion rate than a subtalar fusion following an ankle arthrodesis. Although the time to healing was relatively long, various hindfoot fusions were used to treat progressive arthritis and deformity with high fusion rates.
Level III, comparative case series.
Pressure pain threshold (PPT) is a useful tool for evaluating mechanical sensitivity in patients suffering from various musculoskeletal disorders. However, no previous study has investigated PPT in the heel of patients experiencing plantar heel pain syndrome (PHPS). The aim of this study was to compare PPT levels and topographic presentation of sensitivity in the heel of patients with PHPS and in healthy controls.
The reliability of PPT testing in patients with PHPS was assessed for intra- and interrater recordings. The PPT levels of 40 feet in each group were then assessed on 5 predetermined sites in the heel using a standardized measurement protocol. Patient functional status (FS) as measured by the Foot & Ankle Computerized Adaptive Test was employed as an external reference.
Multivariate analysis of covariance revealed no group differences for PPTs at all sites (P = .406). Age (P = .099) or BMI (P = .510) did not affect PPT values, although there was an effect on gender (P = .006). The analysis revealed significant differences between sites (P < .001) demonstrating a diverse topographic distribution. In the PHPS group, PPT levels at the anterior/medial, posterior/medial and central sites were significantly lower than at the posterior/lateral and anterior/lateral sites (P < .05). For the control group, PPT levels at the anterior/medial site were significantly lower than all other sites (P < .001).
No significant differences were found between PPT of the PHPS patients and controls, therefore, PPT cannot be recommended as an assessment tool for these patients. The topographic distribution indicated low PPT levels at the anterior/medial area of the heel in patients with PHPS and controls.
Level II, comparative study.
Arthrodesis is a common operative procedure used to manage arthritis and deformity in the foot and ankle. Nonunion is a possible and undesirable outcome in any arthrodesis surgery. Rates of nonunion in the foot and ankle literature range from 0% to 47% depending on the patient population and joint involved. Multiple factors can contribute to developing a nonunion including location, fixation method, tobacco use, diabetes, infection, and others.
The case logs of 3 foot and ankle surgeons were reviewed from January 2007 to September 2014 to identify nonunion arthrodesis revision cases. The patient factors reviewed included diabetes, inflammatory arthropathy, tobacco use, history of infection, nonunion elsewhere, neuropathy, Charcot arthropathy, posttraumatic arthritis, and prior attempt at revision arthrodesis at the same site. Operative records were reviewed to identify location of the nonunion, instrumention, use of allograft or autograft bone, use of iliac crest bone marrow aspirate (ICBMA) and use of orthobiologics such as bone morphogenetic protein (BMP) during the revision arthrodesis. Successful revision was defined as radiographic union on the final radiograph during follow-up. Eighty-two cases of revision arthrodesis were identified with an average follow-up of 16 months.
The overall nonunion rate was 23%. Neuropathy and prior attempts at revision were identified as significant risks (P <.05) for persistent nonunion. Odds ratio calculated based on previous attempts at revision arthrodesis found a 2.8-fold increase in the risk of failure for each attempt at revision.
Revision arthrodesis for nonunion in the foot and ankle was successful (77%) under a variety of patient and operative conditions. Neuropathy was a significant patient risk factor for persistent nonunions, and we believe it is important to identify even in the nondiabetic patient. As the number of attempts at revisions increases, there is a subsequent 3-fold increase in the risk of persistent nonunion.
Level IV, case series.
This study aimed to evaluate the long-term follow-up results of V-Y tendon plasty with fascia turndown, for repairing chronic Achilles tendon ruptures.
Seventeen patients (12 males, 5 females), who were diagnosed with chronic Achilles tendon rupture and met the inclusion criteria, were included in the study. These patients received treatment by means of V-Y tendon plasty with fascia turndown from January 1995 to December 2001. Clinical outcomes of the patients were assessed by using isokinetic strength testing, questioning the patient regarding residual discomfort, pain, or swelling and having the ability to perform heel rises and using American Orthopaedic Foot & Ankle Society’s (AOFAS’s) Ankle-Hind Foot Scale score. Mean follow-up duration was 16 years (13-18 years).
Mean time from the injury to operative treatment was 7 months. Mean operative defect of Achilles tendon in neutral position after debridement was 6 cm. During the follow-up, the mean calf atrophy was 3.4 cm. The mean 30 degrees/s plantarflex and 120 degrees/s plantarflex peak torques were 89 and 45 Nm, respectively. The mean 30 degrees/s plantarflex peak torque deficiency was 16%. The mean 120 degrees/s plantarflex peak torque deficiency was 17%. The average peak torque deficiency was 17%. The pre- and postoperative mean AOFAS Ankle-Hindfoot Scale scores were 64 and 95, respectively. No patient had a rerupture. Superficial wound infection was treated with oral antibiotic therapy in 2 patients (11%).
The V-Y tendon plasty with fascia turndown for repairing chronic Achilles tendon ruptures yielded results comparable with the literature regarding clinical outcomes. This method did not require synthetic materials for augmentation and was an economic alternative compared to other repair methods.
Level III, retrospective comparative study.
Patients with arthritis or severe dysfunction involving both the ankle and subtalar joints can benefit from tibiotalocalcaneal (TTC) arthrodesis or total ankle replacement and subtalar fusion. TTC fusion is considered by many as a salvage operation resulting in a stiff ankle and hindfoot, considerably limiting global foot function. With the evolution of prosthetic design and operative techniques, total ankle replacement (TAR) has become a reasonable alternative to arthrodesis. The aim of this study was to investigate the fusion rate of the subtalar joint in patients simultaneously treated with total ankle replacement (TAR) and subtalar joint fusion.
This study included 25 patients who underwent primary TAR and simultaneous subtalar fusion between May 2011 and November 2014. Sixteen males (64%) and 9 females (36%) were enrolled with a mean age of 58 years (25-82). Patients were clinically assessed preoperatively and at 6 and 12 months postoperatively. Total follow-up time was 24.2 ± 11.6 months. Radiographic examination included a postoperative computed tomographic (CT) scan obtained 12 months after surgery. Three surgeons independently reviewed the CT scans and interobserver reliability was calculated. Functional scores were also assessed.
At 12 months postoperatively, the subtalar fusion rate in patients treated with TAR and simultaneous subtalar fusion was 92%. There was a statistically significant increase in American Orthopaedic Foot & Ankle Society ankle/hindfoot score from 27.9 to 75.1. Ankle range of motion significantly increased from 12 to 32.8 degrees. Additionally, there was a statistically significant decrease in visual analog scale pain score from 8.6 to 2.1.
TAR and simultaneous subtalar joint fusion were reliable procedures for the treatment of ankle and subtalar joint arthritis. Furthermore, CT scans showed an excellent reliability among orthopedic surgeons in determining the degree of successful fusion of subtalar arthrodesis.
Level IV, case series.
The purpose of this study was to assess the effect of insurance type (Medicaid, Medicare, and private insurance) on access to foot and ankle surgeons for total ankle arthroplasty.
We called 240 foot and ankle surgeons who performed total ankle arthroplasty in 8 representative states (California, Massachusetts, Ohio, New York, Florida, Georgia, Texas, and North Carolina). The caller requested an appointment for a fictitious patient to be evaluated for a total ankle arthroplasty. Each office was called 3 times to assess the responses for Medicaid, Medicare, and BlueCross. From each call, we recorded appointment success or failure and any barriers to an appointment, such as need for a referral.
Patients with Medicaid were less likely to receive an appointment compared to patients with Medicare (19.8% vs 92.0%, P < .0001) or BlueCross (19.8% vs 90.4%, P < .0001) and experienced more requests for referrals compared to patients with Medicare (41.9% vs 1.6%, P < .0001) or BlueCross (41.9% vs 4%, P < .0001). Waiting periods were longer for patients with Medicaid compared to those with Medicare (22.6 days vs 11.7 days, P = .004) or BlueCross (22.6 days vs 10.7 days, P = .001). Reimbursement rates did not correlate with appointment success rate or waiting period.
Despite the passage of the PPACA, patients with Medicaid continue to have difficulty finding a surgeon who will provide care, increased need for a primary care referral, and longer waiting periods for appointments.
Level II, prognostic study.
Hallux valgus is one of the most common foot deformities. This long-term follow-up study compared the results of 2 widely used operative treatments for hallux valgus: the scarf and chevron osteotomy.
Conventional weight bearing anteroposterior (AP) radiographs of the foot were made for evaluating the intermetatarsal angle and hallux valgus angle. For clinical evaluation, the American Orthopaedic Foot & Ankle Society (AOFAS) rating system for the hallux metatarsophalangeal-interphalangeal scale was used together with physical examination of the foot. These data were compared with the results from the original study. The Short Form 36 questionnaire, the Manchester-Oxford Foot Questionnaire (MOXFQ), and a general questionnaire including a visual analog scale (VAS) pain score were used for subjective evaluation. The primary outcome measures were the radiologic recurrence of hallux valgus and reoperation rate of the same toe. Secondary outcome measures were the results from the radiographs and subjective and clinical evaluation. The response rate was 76% at the follow-up of 14 years; in the chevron group, 37 feet were included compared with 36 feet in the scarf group.
Twenty-eight feet in the chevron group and 27 in the scarf group developed recurrence of hallux valgus (P = .483). One patient in the scarf group had a reoperation of the same toe compared with none in the chevron group (P = .314). Current VAS pain scores and results from the SF-36, MOXFQ, and AOFAS did not significantly differ between groups.
Both techniques showed similar results after 2 years of follow-up. At 14 years of follow-up, neither technique was superior in preventing recurrence.
Level II, randomized controlled trial.
Studies have demonstrated improved ankle dorsiflexion and pain reduction following a gastrocnemius recession (GR) procedure. However, changes in muscle performance during functional activities are not known. The purpose of this study was to determine the effect of an isolated GR on ankle power and endurance in patients with Achilles tendinopathy.
Fourteen patients with chronic unilateral Achilles tendinopathy and 10 healthy controls participated in this study. Patient group data were collected 18 months following GR. Pain was compared to preoperative values using a 10-cm visual analog scale (VAS). Patient-reported outcomes for activities of daily living (ADL) and sports were assessed using the Foot and Ankle Ability Measure (FAAM). Kinematic and kinetic data were collected during gait, stair ascent (standard and high step), and repetitive single-limb heel raises. Between-group and side-to-side differences in ankle plantarflexor muscle power and endurance were evaluated with appropriate t tests.
Compared with preoperative data, VAS pain scores were reduced (pre 6.8, post 1.6, P < .05). Significant differences were observed between GR and Control groups for FAAM scores for both ADL (GR 90.0, Control 98.3, P = .01) and Sports subscales (GR 70.6, Control 94.6, P = .01). When compared to controls, ankle power was reduced in the involved limb of the GR group for all activities (all P < .05). Between-group and side-to-side deficits (GR group only) were also found for ankle endurance.
The gastrocnemius recession procedure provided significant pain reduction that was maintained at the 18-month follow-up for patients with chronic Achilles tendinopathy who failed nonoperative interventions. There were good patient-reported outcomes for activities of daily living. However, compared to controls, ankle plantarflexion power and endurance deficits in the GR group were noted. The functional implications of the muscle performance deficits are unclear, but may be reflective of patients’ self-reported difficulty during more challenging activities.
Level III, comparative study.
The goal of this study was to objectively assess if rotational or translational syndesmotic malreduction is associated with certain syndesmotic morphologies. Prior studies based on subjective assessment of syndesmotic morphology and reduction have not shown any difference between groups.
Thirty-five prospectively recruited patients with operatively treated syndesmotic injuries were recruited at an Urban Level I Trauma Center. Patients underwent postoperative bilateral computed tomographic (CT) scans of the ankle to assess incisura depth and syndesmotic reduction. The uninjured extremity was used as a control. Side-to-side differences of syndesmotic reduction were measured at several anatomic points and compared to the incisura depth.
There was a significant correlation between more shallow syndesmoses and increased anterior translation of the fibula in the incisura (r = –0.63, P ≤ .001). Six of 8 patients with "shallow" (≤2.5 mm) incisura were anteriorly malreduced greater than or equal to 1.5 mm compared to the contralateral ankle. The anterior malreduction rate in those with a shallow incisura was significantly greater than in the "non-shallow" patients (P < .001). There were 9 patients with incisurae greater than or equal to 4.5 mm deep. Five of the "deep" patients had posterior malreductions greater than or equal to 1.5 mm. The posterior malreduction rate in the "deep" group was significantly greater than the "non-deep" patients (P = .02). There was a significant correlation between increasing syndesmotic depth and increased malrotation (r = .46, P = .01).
Syndesmotic morphology was found to be associated with specific malreduction patterns. Shallow syndesmoses were correlated with anterior fibular malreduction, and were less likely to be malrotated. Conversely, deep syndesmoses predisposed to posterior sagittal plane and rotational malalignment. Preoperative CT scans that assess the syndesmosis morphology may allow surgeons to alter reduction strategies to avoid syndesmotic malreduction.
Level III, retrospective cohort study.
The current gold standard in the treatment of severe hallux rigidus is arthrodesis of the first metatarsophalangeal (MTP-I) joint. We present the results of a new 3-component MTP-I prosthesis. We determined (1) the intraoperative and perioperative complications; (2) survivorship of prosthesis components and rate of secondary surgeries for any reason; (3) prosthetic component stability and radiographic alignment; (4) the degree of pain relief; and (5) the midterm functional outcomes including radiographic range of motion (ROM).
From 2008 to 2010, we prospectively included 29 MTP-I prostheses in 25 patients. The average age of the patients was 63.1 years (range, 48-87 years). The average follow-up was 49.5 months (range, 36-62 months). We observed complications and reoperations. A visual analog scale for pain and the American Orthopaedic Foot & Ankle Society (AOFAS) forefoot score were obtained pre- and postoperation. Component stability and alignment were assessed using weight-bearing radiographs. Fluoroscopy was used to determine radiographic MTP-I ROM.
Seven (24.1%) patients underwent 1 or more secondary surgeries. Four cases (13.7%) eventually had a conversion to MTP-I arthrodesis. Two patients (3 cases) died from causes not related to the procedure. This left 22 feet in 19 patients for final follow-up. All but 3 remaining prostheses showed stable osteointegration and no migration, but MTP-I alignment showed high variability. The average pain score decreased from 5.9 (range, 3-9) to 1.2 (range, 0-5). The average AOFAS forefoot score increased from 55 (range, 0-80) to 83.5 (range, 58-95). Range of motion initially increased from 37.8 degrees (range, 0-60 degrees) to 88.6 degrees (range, 45-125 degrees) intraoperatively and decreased to 29.0 degrees (range, 11-52 degrees) at latest follow-up.
Our data suggest that total arthroplasty of MTP-I leads to a high amount of revision surgeries, but the remaining patients had significant pain relief at midterm follow-up. However, we observed high variability regarding the prosthesis component alignment and poor range of motion.
Level IV, prospective cohort study.
Abnormalities of the peroneal tendons can frequently be identified on routine MRI of the foot and ankle. Previous studies in the orthopedic literature have discussed the prevalence of abnormal MRI findings in asymptomatic patients, most notably with regards to the spine and shoulder. The purpose of this study was to determine the prevalence of abnormal findings of the peroneal tendons on MRI in asymptomatic individuals.
We retrospectively reviewed all foot and ankle MRIs from 2 independent time periods that were either performed or reviewed at our institution. Studies were excluded if performed on patients with documented inversion injuries, ankle sprains, or lateral ankle trauma. A total of 294 (of 617) MRIs were eligible for inclusion in this study. A single attending musculoskeletal radiologist reviewed each MRI. Pathologies of the peroneal tendons included tendinosis, tenosynovitis, acute tears, chronic tears, and tendon splits. Additionally, the primary pathology encountered on each MRI was noted. The mean age of the MRIs included in this study was 46.8 years (range 9-82) with 155 females and 139 males.
The most commonly occurring primary pathology was Achilles tendinosis/tears (86), followed by posterior tibial tendon dysfunction (43). With regards to the peroneal tendons, 103 of the 294 (35%) MRIs demonstrated some pathology.
The results of this study demonstrated that a sizeable percentage of asymptomatic individuals could have peroneal tendon pathology on MRI of the foot and ankle. This study can have important clinical implications for when patients present with concerning MRI findings that do not correlate clinically. Physicians providing musculoskeletal care can counsel and reassure patients who present with peroneal pathology on MRI but an absence of clinical findings.
Level IV, case series.
The normal distal tibiofibular joint is strongly stabilized by the syndesmosis, where previous cadaveric, biomechanical studies demonstrated only minimal widening and posterior translation of the fibula in external rotation of the ankle. However, little is known about normal rotational dynamics of the distal tibiofibular joint in upright weight-bearing conditions. The purpose of this study was to investigate the normal anatomy and rotational dynamics of the distal tibiofibular joint under physiological conditions on weight-bearing cone beam computed tomography (WBCT).
In a cross-sectional study of 32 subjects, low-dose WBCT scans of uninjured bilateral ankles were performed. Normal intersubject and intrasubject variation in neutral position and changes in maximal internal and external rotation of the ankle were studied. Sagittal translation of the fibula, anterior and posterior widths of the distal tibiofibular syndesmosis, tibiofibular clear space (TFCS), and rotation of the fibula were measured.
In the neutrally loaded ankle, the fibula was located anteriorly in the tibial incisura in 88% of the subjects. When the ankle was rotated, mean anteroposterior motion was 1.5 mm and mean rotation of the fibula was 3 degrees. There was no significant change in TFCS between internal and external rotation. Large intersubject variation was detected, but intrasubject variation between ankles was less than 1 mm and 1 degree.
This study provides reference values to evaluate the dynamics of the normal distal tibiofibular joint. The internal control of the contralateral ankle seemed to be a better reference than the population-based normal values.
The current study provides the reference values to evaluate the rotational dynamics of a normal distal tibiofibular joint.
Metatarsalgia is frequently associated with hallux valgus. The aim of this study was to evaluate how the relative length and position of the first metatarsal head influenced metatarsalgia and plantar callosities beneath the lesser metatarsal heads.
A retrospective analysis of the clinical data and radiographs of 102 cases was performed at a mean follow-up of 16 months after biplane interlocking osteotomies. Clinical evaluation was made using the Japanese Society for Surgery of the Foot (JSSF) hallux scale. Radiologic evaluation was made with standard weight-bearing anteroposterior radiographs, and the hallux valgus angle (HVA), intermetatarsal 1-2 angle (IMA), distal metatarsal articular angulation (DMAA), and the sesamoid position were evaluated. Relative first metatarsal length (RML) was determined according to Nilsonne/Morton’s technique.
The mean preoperative HVA decreased from 37 to 3 degrees, and the mean IMA from 17 to 4 degrees. The mean JSSF-hallux score improved from 56 to 96 points. The mean preoperative area of plantar callosities decreased from 3.1 to 1.5 mm2. Sixty percent of metatarsalgia cases improved, and 85% of painless callosities disappeared postoperatively. Among radiologic parameters, postoperative RML was most significantly associated with JSSF score (P < .0001) and the presence of postoperative metatarsalgia (P < .0001). Receiver operating characteristic analysis revealed that the RML cut-off point was –3 mm for avoiding metatarsalgia, with an area under the curve of 0.88, a specificity of 88%, and a sensitivity of 85%.
Preservation of relative first metatarsal length during first metatarsal osteotomy was important to prevent postoperative metatarsalgia.
Level IV, retrospective case series.
The distal tibiofibular syndesmosis is disrupted in up to 45% of operatively treated ankle fractures, and syndesmotic malreduction has historically been correlated with poor outcome. The purpose of this study was to quantify the clamp force used during syndesmotic reduction and to evaluate the effect of clamp force on fibular overmedialization (overcompression) at the level of the distal tibiofibular syndesmosis.
A prospectively recruited cohort of 21 patients underwent operative syndesmotic reduction and fixation. A ball point periarticular reduction forceps that was modified to include a load cell in one tine was used for the reduction, and the clamp force required for reduction was measured. Patients underwent postoperative bilateral computed tomographic scans of the ankle and hindfoot to assess syndesmotic reduction. The uninjured extremity was used as a control. Side-to-side differences in fibular medialization, translation, and rotation within the tibial incisura were measured. These findings were correlated with the reduction clamp force utilized to obtain the reduction.
Syndesmotic overcompression (fibular medialization greater than 1.0 mm when compared with noninjured ankle) was seen in 11 of 21 patients (52%). Increased clamp force significantly correlated with syndesmotic overcompression. The mean reduction clamp forces were 88 N for the undercompressed group, 130 N for the adequately compressed group, and 163 N for the overcompressed group.
This study demonstrated a significant correlation between increased clamp forces and syndesmotic overcompression, and determined objective forces that lead to overcompression. Our results indicate that surgeons should be cognizant of the clamp force used for syndesmotic reduction.
Level III, case-control series, in accordance with STROBE guidelines.
Concomitant tears of the peroneus longus and brevis tendons are rare injuries, with literature limited to case reports and small patient series. Only 1 recent study directly compared the results of single-stage lateral deep flexor transfer, and no previous series objectively evaluated power and balance following transfer. The purpose of this study was to evaluate clinical outcomes, patient satisfaction, and objective power and balance data following single-stage flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendon transfers for treatment of concomitant peroneus longus and brevis tears.
Over an 8-year period (2005-2012), 9 patients underwent lateral transfer of the FHL or FDL tendon for treatment of concomitant peroneus longus and brevis tears. All but 1 patient underwent additional procedures to address hindfoot malalignment or other contributing deformity at the time of surgery. Mean age was 56.9 years, and average body mass index was 27.9. Lateral transfer of the FHL was performed in 5 patients, and FDL transfer performed in 4 with mean follow-up 35.7 months (range: 11-94). Eight of 9 patients completed SF-12 and Foot Function Index (FFI) scores, and 7 returned for range of motion (ROM) and manual strength testing of the involved and normal extremities. These 7 patients also completed force plate balance tests, in addition to peak force and power testing on a PrimusRS machine with a certified physical therapist.
All patients were satisfied with the results of the procedure. Mean SF-12 physical and mental scores were 32 and 55, respectively; mean FFI total score was 56.7. No postoperative infections were noted. Two patients continued to utilize orthotics or braces, and 2 patients reported occasional pain with weightbearing activity. Three patients noted mild paresthesias in the distribution of the sural nerve and 2 demonstrated tibial neuritis. All patients demonstrated 4/5 eversion strength in the involved extremity. Average loss of inversion and eversion ROM were 24.7% and 27.2% of normal, respectively. Mean postoperative eversion peak force and power were decreased greater than 55% relative to the normal extremity. Patients demonstrated nearly 50% increases in both center-of-pressure tracing length and velocity during balance testing. There were no statistically significant differences between the FHL and FDL transfer groups with regards to clinical examination or objective power and balance tests.
The FHL and FDL tendons were both successful options for lateral transfer in cases of concomitant peroneus longus and brevis tears. Objective measurements of strength and balance demonstrated significant deficits in the operative extremity, even years following the procedure. These differences, however, did not appear to alter or inhibit patient activity levels or high satisfaction rates with the procedure. Although anatomic studies have demonstrated benefits of FHL transfer over the FDL tendon, further studies with increased patient numbers are needed to determine if these differences are clinically significant.
Level IV, retrospective case series.
We introduce a novel method of combining the standard anteromedial and anterolateral approaches and dual posterolateral approaches in the arthroscopic treatment of posterior and anterior ankle impingement syndrome and compare the postoperative outcomes with conventional anteromedial/anterolateral and posteromedial/posterolateral approaches.
From January 2013 to January 2015, we treated 28 patients with posterior and anterior ankle impingement syndrome by arthroscopy. The patients were divided into the conventional group (n = 13) and the modified group (n = 15) according to the surgical approaches used in the operation. Preoperative and postoperative American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale (VAS) score, range of ankle motion, and operation time were recorded. The average follow-up was 16 months (range 6-24 months).
Posterior and anterior ankle impingement syndrome was confirmed arthroscopically in all patients. After the operation, the range of ankle motion in all patients was restored. There was no significant difference in postoperative AOFAS score, VAS score, dorsiflexion, and plantarflexion between the conventional group and the modified group. Moreover, the operation time was significantly reduced in the modified group compared with the conventional group. There was no recurrence of osteophyte and no complications such as infection, neurovascular injury, or delayed healing of surgical incision in the modified group.
Dual posterolateral approaches combined with standard anteromedial and anterolateral approaches was a novel method for arthroscopic treatment of posterior and anterior ankle impingement syndrome. It proved to be safe and effective, and significantly reduced the operation time. Reposition, repeated prep and drape, and limb distraction were avoided.
Level IV, retrospective case series.
Limited-open and percutaneous Achilles tendon (AT) repair techniques have limited visibility, which may result in sural nerve violation and poor tendon targeting. The goal of this study was to assess the in vivo rotation of the AT and its distance to the sural nerve in ruptured and nonruptured ATs to develop guidelines to aid in limited-open and percutaneous repair techniques.
A retrospective review was conducted to identify magnetic resonance imaging (MRI) studies of patients with ruptured and healthy (nonruptured) ATs. AT rotation and distance to the sural nerve in the anterior-posterior (A-P) and medial-lateral (M-L) planes were measured at the level of and proximal to the ankle.
The AT was externally rotated in both ruptured and nonruptured cohorts. Ruptured ATs showed greater external rotation than nonruptured ATs at the ankle (15.8 ± 16.2 degrees vs 5.9 ± 9.0 degrees, P = .008) but not at 10 cm proximal to the tendon’s insertion (10.9 ± 10.9 degrees vs 6.1 ± 8.4 degrees, P = .139). Proximal AT rotation was negatively correlated with rupture height (r = –0.477, P = .029). At 4 cm proximal to the AT insertion, the sural nerve was closer anteriorly to and farther laterally from the AT in ruptures than in nonruptures (P < .001). At 10 cm proximal to the AT insertion, the sural nerve was farther posteriorly and laterally from the AT in ruptures than in nonruptures (P = .027 and P < .001, respectively).
We found that the AT was more externally rotated in ruptured than in nonruptured tendons at the ankle and that its distance to the sural nerve differed between the 2 cohorts in the A-P and M-L planes, likely due to increased AT rotation and swelling with ruptures. To minimize sural nerve injury and improve tendon targeting, we suggest an external rotation of 11 degrees at the proximal end of the rupture and 16 degrees at the distal end when using percutaneous and limited-open AT repair devices to try to minimize sural nerve violation and increase tendon capture, which can decrease rates of complication and rerupture.
Level III, retrospective comparative study.
Access to the medial half of the talus can be challenging even with an osteotomy. Although several techniques are presented in the literature, critical evaluation of fixation, union, and alignment is lacking. The chevron medial malleolar osteotomy provides advantages of perpendicular instrumentation access and wide exposure to the medial talus. Postoperative displacement resulting in malunion, and possibly provoking ankle osteoarthritis, is a known complication. The present study describes our experience with the osteotomy.
A consecutive series cohort of 50 bi-plane chevron osteotomies performed from 2004 to 2013 were evaluated. Forty-six were secured using 2 lag screws, and 4 were secured using 2 lag screws and a medial buttress plate. Radiographic studies performed at 2, 6, and 12 weeks and at final follow-up were analyzed for postoperative displacement, malunion, non-union, and hardware-related complications.
At initial postoperative follow-up, 47 of 50 had adequate radiographs for review, and 18 of 47 (38.3%) showed some displacement when compared to the initial osteotomy fixation position. By final follow-up, 15 of 50 (30.0%) had measurable incongruence. Hardware removal was performed in 13 (26.0%) cases at an average of 2.4 years postoperation.
Bi-plane medial malleolar chevron osteotomy fixed with 2 lag screws showed a 30.0% malunion rate with an average of 2 mm of incongruence on final follow-up radiographs, which is higher than what has been reported in the literature. In our practice, we now use a buttress plate and more recently have eliminated postoperative osteotomy displacement.
Level IV, retrospective case series.
An Achilles sleeve avulsion occurs when the tendon ruptures distally from its calcaneal insertion as a continuous "sleeve." This relatively rare injury pattern may not be appreciated until the time of surgery and can be challenging to treat because, unlike a midsubstance rupture, insufficient tendon remains on the calcaneus to allow for end-to-end repair, and unlike a tuberosity avulsion fracture, any bony element avulsed with the tendon is inadequate for internal fixation. This study aimed to highlight the characteristics of Achilles sleeve avulsions and present the outcomes of operative repair using suture anchor fixation.
A retrospective analysis was conducted on 11 consecutive Achilles tendon sleeve avulsions (10 males, 1 female; mean age 44 years) that underwent operative repair between 2008 and 2014. Patient demographics, injury presentation, and operative details were reviewed. Postoperative outcomes were collected at a mean follow-up of 38.4 (range, 12-83.5) months, including the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score, visual analog scale (VAS) for pain, plantarflexion strength, patient satisfaction, and complications.
Eight patients (72.7%) had preexisting symptoms of insertional Achilles disease. Ten of 11 (90.9%) injuries were sustained during recreational athletic activity. An Achilles sleeve avulsion was recognized preoperatively in 7 of 11 (64%) cases, where lateral ankle radiographs demonstrated a small radiodensity several centimeters proximal to the calcaneal insertion. Intraoperatively, 90.9% of sleeve avulsions had a concomitant Haglund deformity and macroscopic evidence of insertional tendinopathy. All patients healed after suture anchor repair. The average AOFAS score was 92.8 and VAS score was 0.9. Ten patients (90.9%) were completely satisfied. One complication occurred, consisting of delayed wound healing.
Achilles tendon sleeve avulsions predominantly occurred in middle-aged men with preexisting insertional disease, while engaged in athletic activity. Suture anchor fixation, combined with addressing concomitant insertional pathology, was a reliable and safe technique for the operative management of Achilles tendon sleeve avulsions. The majority of patients returned to their preinjury levels of work and recreational activity.
Level IV, retrospective case series.
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.
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.
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.
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 II, lesser quality RCT or prospective comparative study.
Deformation of the talus and the distal tibia can be frequently observed during ankle joint osteoarthritis (OA). The aim of this study was to objectify these morphologic changes. We hypothesized that a flattening of the talus and a broadening of the distal tibia surface occurs in end-stage OA of the ankle joint.
Twenty-seven computed tomography (CT) ankle joint examinations of unilateral ankle OA were matched by sex and age with 27 CT examinations of healthy ankle joints. Three-dimensional reformatting and measurements were performed with geometry analysis software. The following parameters were assessed: sagittal radius of the talus, talus height, and mediolateral and anteroposterior width of the distal tibial joint surface.
Medial, midsagittal, and lateral sagittal arc radii of osteoarthritic tali were significantly larger compared to tali of controls. There was a statistically significant difference in the height of the osteoarthritic talar dome in the medial and in the lateral frontal segment and in the medial central segment compared to tali of controls. The anteroposterior width and the sagittal curvature of the distal tibia was significantly larger in OA ankles than in the control group. The mediolateral measurements were comparable across both groups.
Flattening of the talus appears to be more pronounced in the frontal aspect of the talus. The distal tibia broadens anteroposteriorly. These findings may contribute to better understanding of ankle OA development.
Level III, retrospective comparative cohort study.
No consensus exists regarding the timing of weightbearing after surgical fixation of unstable traumatic ankle fractures. We evaluated fracture displacement and timing of displacement with simulated early weightbearing in a cadaveric model.
Twenty-four fresh-frozen lower extremities were assigned to Group 1, bimalleolar ankle fracture (n=6); Group 2, trimalleolar ankle fracture with unfixed small posterior malleolar fracture (n=9); or Group 3, trimalleolar ankle fracture with fixed large posterior malleolar fracture (n=9) and tested with axial compressive load at 3 Hz from 0 to 1000 N for 250 000 cycles to simulate 5 weeks of full weightbearing. Displacement was measured by differential variable reluctance transducer.
The average motion at all fracture sites in all groups was significantly less than 1 mm (P < .05). Group 1 displacement of the lateral and medial malleolus fracture was 0.1±0.1 mm and 0.4±0.4 mm, respectively. Group 2 displacement of the lateral, medial, and posterior malleolar fracture was 0.6±0.4 mm, 0.5±0.4 mm, and 0.5±0.6 mm, respectively. Group 3 displacement of the lateral, medial, and posterior malleolar fracture was 0.1±0.1 mm, 0.5±0.7 mm, and 0.5±0.4 mm, respectively. The majority of displacement (64.0% to 92.3%) occurred in the first 50 000 cycles. There was no correlation between fracture displacement and bone mineral density.
No significant fracture displacement, no hardware failure, and no new fractures occurred in a cadaveric model of early weightbearing in unstable ankle fracture after open reduction and internal fixation.
This study supports further investigation of early weightbearing postoperative protocols after fixation of unstable ankle fractures.
The first metatarsal bone can shorten after a distal chevron metatarsal osteotomy (DCMO). This shortening can result in a postoperative second metatarsal transfer lesion. The aim of the present study was to investigate the occurrence of second metatarsal transfer lesions after DCMO.
This study involved 185 feet (138 patients), with hallux valgus (HV) deformity, treated with DCMO with Akin osteotomy. The mean patient age was 51.7 years (range, 21 to 74). Patients were followed for an average of 28 months, between June 2004 and June 2010. We measured the length of first metatarsal relative to second metatarsal preoperatively and postoperatively, using Morton’s and Hardy-Clapham’s methods. A second metatarsal transfer lesion was defined as a newly developed lesion, including metatarsalgia, a painful callosity, or a painless callosity, which was not present prior to the DCMO. The relation of the shortened first metatarsal after DCMO with the occurrence of second metatarsal transfer lesion was evaluated.
Second metatarsal transfer lesions (painless callosity) developed in 5 feet (2.7%) of 185 feet. Twenty-four preoperative second metatarsal lesions were improved postoperatively. The median shortening of the first metatarsal bone after DCMO was 0.6 mm according to Morton’s method (range, –6.4 to 6.4), and 1.9 according to Hardy-Clapham’s method (range, –5.8 to 5.8). According to the extent of first metatarsal shortening after DCMO by Hardy-Clapham’s method and Morton’s method, there was no significant difference of the occurrence of second transfer metatarsal lesions (P = .259 and P = .176, respectively).
In our study, second metatarsal transfer lesions developed in 2.7% of feet after DCMO. The occurrence of second metatarsal transfer lesions did not appear to be correlated with the degree of first metatarsal shortening in cases with less than 5.8 mm shortening.
Level IV, retrospective case series.
Open reduction and internal fixation (ORIF), the standard treatment for unstable ankle fractures, has well-known wound complications. Minimally invasive surgery (MIS) has been proposed to decrease these complications. The objectives of this study were to describe an algorithm of MIS for fibular plating and compare the radiographic restoration of fibular anatomy, functional outcomes, and complications between ORIF and MIS for ankle fractures.
This retrospective study included 71 patients with AO/OTA 44-B ankle fractures treated by a single surgeon. ORIF group consisted of 34 patients (54.5-month follow-up) and MIS group was composed of 37 patients (55.9-month follow-up). Among 37 MIS patients, 13 patients were treated with minimally invasive percutaneous plate osteosynthesis and 24 patients with minimally invasive trans-fracture approach according to our MIS algorithm. Operative outcomes were evaluated and compared between the 2 groups by radiographic measurements, functional assessment, and complications.
The MIS group had less blood loss but longer operative time and greater exposure to fluoroscopy. Radiographic measurements revealed similar union time, fibular length, talocrural angle, medial clear space, and tibiofibular clear space in both groups. Lower visual analogue pain score was observed in the MIS group in the early postoperative period. At last follow-up, there were no significant differences regarding pain score, American Orthopaedic Foot & Ankle Society ankle-hindfoot score, and range of motion between the 2 groups. Total complication rate was significantly higher in the ORIF group.
Patients with AO/OTA 44-B fractures treated with MIS fibular plating achieved similar radiographic and functional outcomes but had less pain in the early postoperative period and fewer wound complications compared with those treated with ORIF.
Level III, retrospective comparative study.
Endoscopic gastrocnemius recession has been proposed as a minimally invasive technique for the treatment of isolated gastrocnemius contracture. We report on the safety and efficacy of endoscopic gastrocnemius recession, as an isolated procedure or combined with other concomitant procedures in terms of improvement in ankle dorsiflexion, functional outcome, and postoperative morbidities.
The data were prospectively collected in this case series. Endoscopic gastrocnemius recession was performed by a single surgeon in 320 consecutive patients (344 feet) who were diagnosed with isolated gastrocnemius contracture and failed nonoperative treatments between March 2009 and December 2012. There were 180 women and 140 men with mean age, 47.1 ± 15.7 years. The minimum follow-up was 1 year (mean, 18 months; range, 12 to 53 months). Pre- and postoperative ankle dorsiflexion, pain (Visual Analog Scale [VAS]), SF-36, and Foot Function Index (FFI) were obtained and compared using paired sample t test and Wilcoxon signed-rank test.
The mean ankle dorsiflexion significantly improved from –0.8 ± 5.4 degrees preoperatively to 11.0 ± 6.6 degrees at average of 13 months postoperatively (n = 294) (P < .001). Complete preoperative and 1-year postoperative pain (VAS) (n = 274) and functional outcome scores (n = 185) were collected when possible. The mean pain (VAS) decreased from 7/10 to 3/10 postoperatively (all P < .01). The mean SF-36 including physical component summary score (PCS) and mental component summary score (MCS) increased from 34 and 44 to 45 and 51, respectively (P < .01 for both PCS and MCS). The mean FFI improved from 63 to 42 for pain, 63 to 43 for disability, 68 to 44 for activity limitation, and 61 to 41 for total score postoperatively (all P < .01). Postoperative morbidity included weakness of ankle plantarflexion (N = 11/320; 3.1% respectively) and sural nerve dysesthesia (N = 10/320; 3.4%). Wound complications or Achilles tendon rupture did not occur. There was no difference in the average improvement in ankle dorsiflexion, outcome scores, and rate of complications between the isolated and combined procedures.
Endoscopic gastrocnemius recession demonstrated promising results in the treatment of isolated gastrocnemius contracture. Ankle dorsiflexion was significantly improved with minimal morbidity. The procedure was found effective in improving functional outcomes and relieving pain as a sole operative treatment and as a part of combined procedures in our patients.
Level IV, case series.
There is a paucity of objectively recorded data delineating the pattern of weightbearing distribution within the prosthetic socket of patients with transtibial amputation. Our current knowledge is based primarily on information obtained from finite element analysis computer models.
Four high-functioning transtibial amputees were fit with similar custom prosthetic sockets. Three load cells were incorporated into each socket at high stress contact areas predicted by computer modeling. Dynamic recording of prosthetic socket loading was accomplished during rising from a sitting position, stepping from a 2-leg stance to a 1-leg stance, and during the initiation of walking. By comparing the loads measured at each of the 3 critical locations, anterior/posterior shear, superior/inferior shear, and end weightbearing were recorded.
The same load pattern in all 4 subjects was found during each of the 3 functional activities. The load transmission at the distal end of the amputation residual limbs was negligible. Consistent forces were observed in both the anterior/posterior and superior/inferior planes. Correlation coefficients were used to compare the loads measured in each of the 4 subjects, which ranged from a low of .82 to a high of .98, where a value approaching 1.0 implies a linear relationship amongst subjects.
This experimental model appears to have accurately recorded loading within a transtibial prosthetic socket consistent with previously reported finite element analysis computer models.
This clinical model will allow objective measurement of weightbearing within the prosthetic socket of transtibial amputees and allow objective comparison of weightbearing distribution within the prosthetic sockets of patients who have undergone creation of different versions of a transtibial amputation residual limb and prosthetic socket designs.
The current clinical standard for the surgical treatment of ankle instability remains the open modified Broström procedure. Modern advents in arthroscopic technology have allowed physicians to perform certain foot and ankle procedures arthroscopically as opposed to traditional open approaches.
Twenty matched lower extremity cadaver specimens were obtained. Steinman pins were inserted into the tibia and talus with 6 sensors affixed to each pin. Specimens were placed in a Telos ankle stress apparatus in an anteroposterior and then lateral position, while a 1.7 N-m load was applied. For each of these tests, movement of the sensors was measured in 3 planes using the Optotrak Computer Navigation System. Changes in position were calculated and compared with the unloaded state. The anteriortalofibular ligament and the calcaneofibular ligament were thereafter sectioned from the fibula. The aforementioned measurements in the loaded and unloaded states were repeated on the specimens. The sectioned ligaments were then repaired using 2 corkscrew anchors. Ten specimens were repaired using a standard open Broström-type repair, while the matched pairs were repaired using an arthroscopic technique. Measurements were repeated and compared using a paired t test.
There was a statistically significant difference between the sectioned state and the other 3 states (P < .05). There were no statistically significant differences between the intact state and either the open or arthroscopic state (P > .05). There were no significant differences between the open and arthroscopic repairs with respect to translation and total combined motion during the talar tilt test (P > .05). Statistically significant differences were demonstrated between the 2 methods in 3 specific axes of movement during talar tilt (P = .04).
Biomechanically effective ankle stabilization may be amenable to a minimally invasive approach.
A minimally invasive, arthroscopic approach can be considered for treating patients with lateral ankle instability who have failed conservative treatment.
There is heterogeneity in the literature regarding the anatomy and number of ligamentous bands that form the deltoid ligament (DL). Anatomic knowledge of the DL and its variations are important for surgeons who repair ankle fractures.
The DL was dissected in 33 ankles from 17 formalin-fixed cadavers (mean age at death, 76.6 years) to examine its morphology. The length, width, and thickness of its constituent bands were recorded with a digital caliper. Descriptive and correlational statistics were used to investigate the relationships between band size, age at death, and sex. A literature review was conducted to compare our data to those of previous studies.
The DL has superficial and deep layers with up to 8 different bands.
The DL stabilizes the medial ankle and should be evaluated in flatfoot deformities and severe ankle fractures.
Anatomic knowledge of DL variations should aid the surgeon in repairing torn DLs.
Operative repair of an acute Achilles tendon rupture (ATR) reduces the risk of re-rupture and has therefore gained popularity as a standard treatment for ATR, especially in the young and physically active patient. There is ongoing controversy over the best surgical technique and postoperative treatment. In this prospective, randomized trial, we compared cast immobilization and functional treatment with early mobilization and weightbearing after using a minimally invasive surgical technique in patients with ATR.
All patients with ATR were included. Exclusion criteria were systemic immunosuppressive therapy, re-ruptures, and severe comorbidity. All included patients underwent minimally invasive surgery, after which a below-knee splint with the foot in 10 degrees of plantar flexion was applied for the first week. Patients were then randomized to the cast immobilization group (IG) for 6 weeks or to the functional group (FG) for 6 weeks. Sixty patients were included. Median age was 43 years (range, 19-65), and 78% were male. Most ATRs were sports related. Data were collected preoperatively and during the outpatient checks at 1, 3, and 6 weeks; 3 and 6 months; and 1 year. Outcome parameters were return to work or sport, complications including re-rupture, Achilles rupture performance score (ARPS), loss of strength, range of motion, subjective result, and quality-of-life (QoL) scores.
In our follow-up period, we did not see differences in strength, QoL scores, return to work or sports, or ARPS between the 2 treatment groups. The patients in the FG reported more complaints, mostly pain, in the first weeks after surgery, probably because of the exercise program starting 1 week postsurgery. The overall complication rate was low. In each group, we had 1 re-rupture; in the IG, however, 2 patients had a deep venous thrombosis, despite low-molecular-weight heparin.
The minimally invasive repair of ATR was a safe and reliable technique with good results. Early mobilization seemed to be as safe as more traditional postoperative immobilization with equal patient satisfaction. Although not significantly different, we saw more major complications in the IG.
Level I, prospective randomized trial.
Recombinant human bone morphogenetic protein-2 (rhBMP-2) has been used to augment bone healing and fusion in a variety of orthopaedic conditions. However, there is a paucity of data evaluating the potential benefits of its use in foot and ankle surgery. The purpose of this study was to investigate the effectiveness and associated complications with the use of rhBMP-2 in high-risk foot and ankle fusions and fracture nonunions.
A total of 51 cases in 48 patients undergoing foot and ankle fusions or fracture nonunion revisions and considered at high risk for subsequent nonunion were identified through a retrospective review in which rhBMP-2 was used as an augment for bone healing. Rate of union, time to union, and associated complications were evaluated.
Forty-seven of 51 high-risk cases treated with rhBMP-2 united for a per-case union rate of 92.2%. Seventy-eight of 82 individual sites treated with rhBMP-2 united for a per-site union rate of 95.1%. Of the successful unions, the mean time to union was 111 days (95% confidence interval, 101-121). There were no statistically significant differences in time to union with regard to supplementation with bone allograft or autograft or size of rhBMP-2 kit used. Complication rates were low.
rhBMP-2 was a safe and apparently effective adjunct to bony union in high-risk foot and ankle surgeries. Further randomized controlled trials are warranted.
IV Retrospective Case Series
Heightened security concerns have made metal detectors a standard security measure in many locations. While prior studies have investigated the detection rates of various hip and knee implants, none have looked specifically at the detection of foot and ankle implants in an in vivo model. Our goals were to identify which commonly used foot and ankle implants would be detected by walkthrough metal detectors both in vivo and ex vivo.
Over a 7-month period, 153 weightbearing patients with foot and ankle hardware were recruited to walk through a standard airport metal detector at 3 different program settings (buildings, airports, and airports enhanced) with a base sensitivity of 165 (arbitrary units), as currently used by the Transportation Security Administration. The number of implants, location and type, as well as the presence of concomitant hardware outside of the foot and ankle were recorded. To determine the detection rate of common foot and ankle implants ex vivo, different hardware sets were walked through the detector at all 3 program settings.
Seventeen patients were found to have detectable hardware at the buildings, airports, and airports enhanced settings. An additional 3 patients had hardware only detected at the airports enhanced setting. All 20 of these patients had concomitant metal implants outside of the foot and ankle from other orthopaedic procedures. All patients with foot and ankle implants alone passed through undetected. Seven hardware sets were detected ex vivo at the airports enhanced setting.
Our results indicate that patients with foot and ankle implants alone are unlikely to be detected by walkthrough metal detectors at standard airport settings. When additional hardware is present from orthopaedic procedures outside of the foot and ankle, metal detection rates were higher. We believe that these results are important for surgeons in order to educate patients on how they might be affected when walking through a metal detector such as while traveling.
Level II, prospective comparative study.
The timing of surgery for osteosynthesis of type C pilon (AO/OTA) fractures remains controversial. The aim of this study was to determine the outcome of early and delayed open reduction and internal fixation (ORIF) for treating closed type C pilon fractures.
Forty-six patients with closed type C pilon fractures matched according to age, gender, soft tissue conditions, and fracture pattern were divided into group A (early group: underwent surgery within 36 hours of the injury) or group B (delayed group: underwent surgery 10 days to 3 weeks postinjury after the soft tissue swelling subsided). In the delayed group, 9 patients were treated first by temporary external fixation. All the closed fractures were managed by ORIF with locking plates. At follow-up, the clinical and radiographic results were retrospectively analyzed. The mean follow-up time was 25.8 months (range, 14 to 48 months) in group A and 26.0 months (range, 15 to 44 months) in group B.
There was no significant difference (P > .05) between the 2 groups regarding the rate of soft tissue complication, the rate of fracture union, and the final functional score. The patients in group A had a significantly shorter mean time to fracture union (21.5 ± 4.0 weeks vs 23.3 ± 3.7 weeks, P < .05), operating time (84.3 ± 12.1 months vs 100.6 ± 13.7 months, P < .01), and hospital stay (7.6 ± 2.6 days vs 15.2 ± 4.2 days, P < .01).
If soft tissue conditions are acceptable, early ORIF for treating closed type C pilon fractures can be safe and effective, with similar rates of wound complication, fracture union, and final good functional recovery but shorter operative time, union time, and hospital stay. These results favorably compare with delayed ORIF treatment.
Level III, retrospective comparative study.
The literature on salvage procedures for failed total ankle replacement (TAR) is sparse. We report a series of 17 patients who had a failed TAR converted to a tibiotalar or a tibiotalocalcaneal arthrodesis.
Between 2003 and 2012, a total of 17 patients with a failed TAR underwent an arthrodesis. All patients were followed on a regular basis through chart review, clinical examination and radiological evaluation. The following variables were analyzed: pre- and postoperative Meary angle, cause of failure, method of fixation, type of graft, time to union, complications, and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score. The average follow-up was 30.1 months. The average period from the original arthroplasty to the arthrodesis was 49.8 months.
Thirteen of the 17 ankles were considered radiographically healed after the first attempt in an average time of 3.7 months and 3 after repeat arthrodesis. Bone grafts were used in 16 patients. The median postoperative AOFAS score was 74.5. The mean Meary angle of the hindfoot was 5 degrees of valgus.
Tibiotalar and tibiotalocalcaneal arthrodeses were effective salvage procedures for failed TAR. Massive cancellous allografts were a good alternative to compensate for the large bone defect after removal of the prosthesis and to preserve the leg length.
Level IV, retrospective case series.
Sensory nerve dysfunction in patients with hallux valgus has been described as both a symptom of the deformity and a complication of the treatment. The purpose of this study was to quantify nerve dysfunction in hallux valgus patients and to prospectively evaluate whether the trauma of surgery or the correction of the deformity had any effect on the sensory nerve function.
Fifty-seven consecutive feet undergoing operative correction for hallux valgus were prospectively enrolled. Preoperative and 3-, 6-, and 24-month postoperative clinical, radiographic, and detailed sensory examinations were completed. For the sensory examination, a Semmes-Weinstein 5.07 monofilament was used to establish, if present, a geometric area of sensory deficit about the hallux. This area was traced onto calibrated graphing paper and processed with imaging software. A total of 48/57 (84%) went on to complete 24 months of follow-up.
Preoperative sensory area deficit improved by a mean of 529 mm2 at 24-month follow-up. The mean preoperative sensory deficit area was 688 mm2 (SD 681 mm2, range: 0 to 2885 mm2) and 24-month postoperative sensory deficit area was 159 mm2 (SD 329 mm2, range: 0 to 1463 mm2). No clinically significant correlation existed between deficit and clinical outcome measures.
This study showed that preoperative sensory deficits exist, and can improve up to 24 months after operative correction of the hallux valgus deformity. This supports the concept that sensory deficit in hallux valgus is at least partially caused by a reversible injury to the sensory nerves, not necessarily a complication of surgery.
Level 4, case series.
The relationship between dorsal plate positioning and final dorsiflexion angle after first metatarsophalangeal (MTP) joint fusion has not been well established. The main purpose of this study was to investigate whether changes in dorsal plate positioning along the longitudinal axis affect fusion dorsiflexion angle, as excessive dorsiflexion angles can lead to poor clinical results.
Ten cadaver foot specimens were randomly assigned to 2 groups for first MTP joint fusion: 1 group used a straight plate, and the other group used a 10-degree precontoured plate. After routine preparation, the plates were placed in an "ideal" position based on clinical and radiological examination. The plates were then moved proximally 3 mm and 6 mm from the initial site, with repeat imaging completed at each position. The radiological dorsiflexion angle was determined for each position, and the results were assessed.
Placement of both straight and precontoured plates at positions more proximal from the initial position led to significant increases in dorsiflexion angles (P = .04), although the percentage change was larger in the precontoured plate group (P = .01). While placement of the plate 3 mm proximal from the perceived "ideal" position did increase the dorsiflexion angle, the percentage of specimens with dorsiflexion angles in the suggested optimal range changed minimally. Positioning at 6 mm from the starting point, however, led to significantly increased dorsiflexion angles for both plates (P = .004).
Positioning the dorsal plate at more proximal locations leads to increasing dorsiflexion angles. Precontoured plates are more likely to lead to excessive dorsiflexion compared with straight plates regardless of plate position.
Fusion at excessive dorsiflexion angles can be minimized with appropriate selection and proper positioning of the dorsal fusion plate along the longitudinal axis.
Chronic Achilles tendon ruptures are associated with considerable functional morbidity. When treated operatively, debridement of degenerated tendon ends may create large defects. Various procedures to reconstruct large defects have been described. We present a simple technique in which an autologous semitendinosus tendon graft is used to reconstruct defects larger than 5 cm in chronic Achilles tendon ruptures. The purpose of this study was to describe our operative technique and its functional outcome.
Achilles ruptures of more than 6 weeks duration were considered for the study. We treated 35 patients (20 males, 15 females) with symptomatic chronic Achilles tendon ruptures. The mean age was 47.4 years (range, 30 to 59). The smallest defect that we had reconstructed was 5 cm, and the largest was 9 cm in length. The average follow-up duration was 30.7 months (range, 20 to 42). Postoperatively, the strength of gastrocsoleus was measured by manual muscle testing (MMT) in non-weight-bearing and weight-bearing positions.
All operated patients showed satisfactory functional outcome, good soft tissue healing, and no reruptures. The preoperative weight-bearing MMT of 2/5 improved to 4/5 or 5/5 postoperatively. In all patients, postoperative non-weight-bearing MMT was 5/5. All patients returned to their prerupture daily activity.
We present a technique that is simple, with low morbidity. We believe it is a valuable option especially when allografts are not available. It is inexpensive as suture anchors or tenodesis screws are not used. This can be a useful option if other tendons (flexor hallucis longus, peroneus brevis, etc) are not available for transfer.
Level IV, retrospective case series.
Large bone defects present a difficult task for surgeons when performing single-stage, complex combined hindfoot and ankle reconstruction. There exist little data in a case series format to evaluate the use of frozen femoral head allograft during tibiotalocalcaneal arthrodesis in various populations in the literature.
The authors evaluated 25 patients from 2003 to 2011 who required a femoral head allograft and an intramedullary nail. The average time of final follow-up visit was 83 ± 63.6 weeks (range, 10-265).
Twelve patients healed the fusion (48%). Twenty-one patients resulted in a braceable limb (84%). Four patients resulted in major amputation (16%).
This series may allow surgeons to more accurately predict the success and clinical outcome of these challenging cases.
Level IV, case series.
Preoperative navigation has provided many potential benefits for total knee arthroplasty, including patient-specific alignment, repeatable implant placement, and decreased operative time. For the first time, this technology was applied to total ankle arthroplasty (TAA). This study evaluated repeatability of tibia and talus patient-specific guide placement and deviation between the preoperative plan and actual implant placement.
Routine ankle CT scans were acquired of 15 cadaveric lower extremity limbs, converted into 3D solid models, and imported into a computer-assisted design assembly. Anatomic landmarks defining tibia/talus alignment were established and used to perform a virtual TAA. Commercially available implant components were placed to mimic traditional cases. An operative guide referencing the cadaver-specific anatomy was engineered to define the resection planes necessary to re-create virtual placement of traditional tibia and talus implants in the postoperative position. Board-certified TAA orthopaedic surgeons with no prior preoperative navigation experience placed the operative guides onto the bones based on tactile and visual feedback. Guide placement was repeated 4 times to determine variability. Final implant position was recorded with an infrared probe, confirmed with CT scans, and compared to the preoperative plan. Average deviations between planned and actual guide placement were determined for all rotational and translational degrees of freedom (DOF). In addition, implant component location was measured radiographically.
Intraobserver tibia and talus guide variation between all trials was 0.26 ± 0.18 degrees and 0.36 ± 0.25 degrees in flexion/extension, 0.61 ± 0.58 and 0.53 ± 0.53 in varus/valgus, and 0.79 ± 0.38 degrees and 1.15 ± 0.77 degrees in internal/external rotation, respectively. Average variation between preoperative and postoperative implant placement was less than 2 degrees and 1.4 mm in all specimens tested.
Preliminary data suggest that preoperative navigation and custom operative guides result in reliable and reproducible placement of TAA implants and patient-specific ankle alignment. Deviation of final implant placement from the preoperative plan was less than 2 degrees in all angular DOF, providing greater accuracy than the ±3 degrees determined in other implant system studies using traditional instrumentation and computer navigation.
We have further demonstrated that final implant position is successfully guided by these patient-specific guides, with reproducibility of tibial component placement falling within 2 degrees of the intended target. This level of reproducibility suggests a promise for this technology, and it is hoped this level of accuracy will become the benchmark for the next generation of total ankle arthroplasty.
Plantar pressure abnormalities after open reduction with internal fixation (ORIF) of intra-articular calcaneal fractures have been observed previously, but high-grade fractures were not selectively investigated and follow-up times were shorter than 2 years. The purpose of this study was to characterize plantar pressure anomalies in patients with exclusively high-grade calcaneal fractures after ORIF with a minimum 2 years of follow-up, and to test the association between plantar pressure distribution and the clinical outcome.
The orthopaedic registry was reviewed to identify patients with isolated high-grade calcaneal fractures (Sanders types III-IV) who were operated on and had a minimum 2 years of follow-up. Sixteen patients were evaluated. Mean age was 47 years and follow-up was between 2 and 6 years. The Pedar-Mobile system was used to measure 3 loading and 3 temporal variables and compare these between the operated and the uninjured limbs.
Mean American Orthopaedic Foot and Ankle Society (AOFAS) score was 76 ± 7 at latest follow-up. Bohler’s angle was 5 ± 8 degrees before surgery and 25 ± 7 degrees at latest follow-up. Stance was shorter in operated limbs (P = .001). Timing of the peak of pressure was delayed in operated limbs under the hallux and the second toe (P ≤ .03). Peak pressure, force time integral, and pressure time integral were increased under the lateral midfoot (P ≤ .03) and decreased under the second metatarsal (P ≤ .03). Force time integral was decreased under the first metatarsal (P = .02) and under the hallux and the lateral toes (P ≤ .05). Increased loading under the lateral midfoot and decreased loading under the lateral toes were correlated with poorer clinical outcome (r = –.53, P < .05, and r = .63, P < .01, respectively).
Side-to-side plantar pressure mismatch persisted at more than 2 years after ORIF of high-grade calcaneal fractures performed via lateral approach, despite improvement of Bohler’s angle. This was characterized by shortened stance phase, delayed timing of peak of pressure under the hallux and second toe, lateral load shift at the midfoot, and decreased toe pressures in operated limbs. Since loading abnormalities were correlated with the clinical outcome, modifications in treatment strategy that can improve foot loading may be desirable in these cases.
Level III, case control.
There is an increasing trend for surgical correction of the deformity associated with Charcot neuroarthropathy of the foot and ankle (Charcot foot) in order to allow ambulation with commercially available therapeutic footwear. The significant rate of surgical and medical morbidity associated with extensive conventional operative correction has led many surgeons to use limited surgical dissection and stabilization with circular ring external fixation.
A retrospective chart review was performed on 254 patients at 2 academic medical centers who underwent surgical correction for diabetes-associated Charcot foot deformity with limited soft tissue dissection and stabilization accomplished with a statically applied circular external fixator. Tibial stress fractures developed in 10 of the patients.
Seven of the fractures developed in the 42 patients in whom tibial block fixation was accomplished with half-pins (16.7%), and 3 fractures developed in the 202 patients in whom tibial block fixation was accomplished with tensioned fine wires (1.5%). Three of the tibial stress fractures were successfully treated with extension of the circular frame above the level of the stress fracture. Four fractures were successfully treated with closed intramedullary nailing and 3 with weight-bearing total contact casts. Two tibial fractures occurred through pin sites (all half-pins) in 120 nonneuropathic patients who underwent application of circular ring external fixators during the same 6-year period.
Tibial stress fracture is an unusual complication associated with the use of circular ring external fixation. This investigation highlights the significantly greater risk for the development of this complication in diabetic patients undergoing surgical correction for Charcot foot deformity when half-pins are used for tibial block stabilization, compared with tensioned fine wires. We now recommend the universal use of tensioned fine wires for tibial block fixation when circular ring fixation is performed in patients with Charcot foot arthropathy.
Level IV, retrospective case series.
Stability and balance are fundamental during static and dynamic activities. The effects of wearing rocker bottom sole (RBS) shoes on the limits of stability (LOS) and adaptation to wearing RBS shoes need to be investigated. The objectives of this study were to evaluate the LOS when wearing RBS shoes, and to evaluate if people improve their stability while wearing RBS shoes over time.
Eleven female subjects with no lower extremity impairments participated in the study. The LOS were tested at baseline and weeks 3 and 6 using a Neurocom SMART EquiTest equipment. Center of pressure (CoP) was determined using force plates, and the center of gravity (CoG) position was estimated from the CoP measures and subjects’ anthropometry. Subjects performed a series of tasks that involved leaning in different directions so as to move the vertical projection of their CoG. End-point excursions of the CoG floor projection were calculated as a percentage of the distance between the starting position and the target. Considering the body as an inverted pendulum, we recorded the average angular velocity of the inverted pendulum during the movements and quantified directional control as a percentage of movement toward versus away from the target. Shoe types were compared using paired t tests, and sessions were compared using repeated measures ANOVA.
The angular velocities of the inverted pendulum (ie, CoG velocity) were not significantly different between shoe conditions in the front and back directions at baseline (4 ± 3 with RBS vs 5 ± 2 deg/sec with regular shoes, and 4 ± 1 vs 6 ± 4 deg/sec). Front directional control of the CoG was significantly worse with RBS shoes at weeks 3 and 6 (P < .015). Front end-point excursions were also lower with RBS shoes both at baseline and week 6 (P < .014). There were no significant changes over time.
The findings indicate that the LOS were negatively affected by wearing RBS shoes and that people do not improve their stability while wearing these shoes even after a 6-week period of use.
This study shows that wearing RBS shoes increase instability and the instability remains even after wearing these shoes for six weeks.
Patient dissatisfaction following surgical correction of hallux valgus remains a clinical problem. The aim of this study was to investigate articular erosion patterns of the first metatarsal head in patients with hallux valgus, to evaluate if the cartilage damage was associated with the degree of hallux valgus deformity, and to prospectively evaluate the effect on patient outcomes.
Fifty-six consecutive feet undergoing surgical correction for hallux valgus were prospectively enrolled and followed for 24 months postoperatively. In addition to clinical and radiographic examinations, intraoperative measurements were obtained to quantify osteochondral lesion location, size, and grade of the first metatarsal head cartilage.
Fifty-one of 56 feet (91%) had osteochondral lesions. The mean number of zones affected was 2.9, and the mean maximum International Cartilage Repair Society (ICRS) scale lesion grade was 2.9 out of 4. A total of 44/56 (79%) completed a minimum of 24 months of follow-up. The grade of the lesion and the extent of the lesion did not have a strong correlation with the radiographic measures or clinical outcome scores.
This study showed a high prevalence of osteochondral lesions in patients undergoing operative correction of hallux valgus. Since the grade and the extent of the lesions did not have a strong correlation with the severity of the deformity or the clinical outcome, the significance of these lesions remains unknown.
Level III, comparative series.
Cavovarus deformity associated with neuromuscular imbalance is a challenging pathology. Most of these deformities lead to pressure symptoms at the lateral border of the foot. This leads to pain, callosity, and commonly fracture of the fifth metatarsal base. This study reports the outcome of a cohort of patients who underwent an adjunctive procedure of resection of the fifth metatarsal, either partial or complete, in conjunction with cavovarus foot reconstruction to offload the lateral border of the foot.
This was a retrospective study looking at the clinical and radiographic outcome of patients with an underlying neuromuscular problem with a cavovarus foot who underwent a resection of the fifth metatarsal. This was used as an adjunctive procedure during reconstruction for lateral foot pressure overload symptoms. Case notes and radiographs were reviewed. The distance on weight-bearing radiographs from the inferior most part of the bony prominence on the lateral border of the foot to the floor was measured and compared between pre- and postoperatively. Eighteen patients met the inclusion criteria. Mean age was 55 years. Mean follow-up was 32 months.
Fourteen patients had a partial base of fifth metatarsal resection, and 4 had a complete fifth ray resection. Radiographic measurements showed a statistically significant improvement in the distance from the inferior most part of the bony prominence on the lateral border of the foot to the floor between pre- and postoperative radiographs. Sixteen patients reported a significant improvement in their symptoms, 2 had some persistent lateral overload symptoms.
The technique described in this study has not been reported previously for this indication. We believe it is a good adjunctive procedure in cavovarus foot reconstruction for patients suffering from lateral pressure overload. We describe strict guidelines and indications for this procedure.
Level IV, case series.
This study compared the operative outcome between retinaculum repair with and without fibular groove deepening for the treatment of recurrent traumatic peroneal tendon dislocation in young, active patients.
A consecutive series of 29 patients who underwent operative treatment of recurrent peroneal tendon dislocation were evaluated. Thirteen patients were treated by the superior peroneal retinaculum repair with fibular groove deepening (group A) and 16 patients by superior peroneal retinaculum repair alone (group B). The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analog scale (VAS) score for pain, and overall patient satisfaction were used to evaluate the clinical outcome after a minimum follow-up period of 12 months postoperatively. In addition, mean time to return to sports activity and tourniquet time were compared between groups.
Mean AOFAS score improved significantly from 59.3 points preoperatively to 92.2 points at the final follow-up in group A and from 58.5 points preoperatively to 91.3 points at the final follow-up in group B. Mean VAS score also improved significantly from 5.0 points preoperatively to 1.0 points at the final follow-up in group A and from 4.9 points preoperatively to 1.2 points at the final follow-up in group B. Improvements in AOFAS and VAS scores at the final follow-up were not significantly different between the 2 groups. Mean time to return to sports activity was approximately 3 months in both groups. Mean tourniquet time in group B was significantly shorter than that in group A (42.2 vs 29.5 min).
Isolated retinaculum repair compared to retinaculum repair with fibular groove deepening was a faster and simpler technique, but both techniques had good outcomes for the treatment of recurrent traumatic peroneal tendon dislocation.
Level II, prospective, nonrandomized, comparative study.
Ipsilateral hindfoot arthrodesis in combination with total ankle replacement (TAR) may diminish functional outcome and prosthesis survivorship compared to isolated TAR. We compared the outcome of isolated TAR to outcomes of TAR with ipsilateral hindfoot arthrodesis.
In a consecutive series of 404 primary TARs in 396 patients, 70 patients (17.3%) had a hindfoot fusion before, after, or at the time of TAR; the majority had either an isolated subtalar arthrodesis (n = 43, 62%) or triple arthrodesis (n = 15, 21%). The remaining 334 isolated TARs served as the control group. Mean patient follow-up was 3.2 years (range, 24-72 months).
The SF-36 total, AOFAS Hindfoot-Ankle pain subscale, Foot and Ankle Disability Index, and Short Musculoskeletal Function Assessment scores were significantly improved from preoperative measures, with no significant differences between the hindfoot arthrodesis and control groups. The AOFAS Hindfoot-Ankle total, function, and alignment scores were significantly improved for both groups, albeit the control group demonstrated significantly higher scores in all 3 scales. Furthermore, the control group demonstrated a significantly greater improvement in VAS pain score compared to the hindfoot arthrodesis group. Walking speed, sit-to-stand time, and 4-square step test time were significantly improved for both groups at each postoperative time point; however, the hindfoot arthrodesis group completed these tests significantly slower than the control group. There was no significant difference in terms of talar component subsidence between the fusion (2.6 mm) and control groups (2.0 mm). The failure rate in the hindfoot fusion group (10.0%) was significantly higher than that in the control group (2.4%; p < 0.05).
To our knowledge, this study represents the first series evaluating the clinical outcome of TARs performed with and without hindfoot fusion using implants available in the United States. At follow-up of 3.2 years, TAR performed with ipsilateral hindfoot arthrodesis resulted in significant improvements in pain and functional outcome; in contrast to prior studies, however, overall outcome was inferior to that of isolated TAR.
Level II, prospective comparative series.
Selecting optimal patient-reported outcome (PRO) instruments is critical to improving the quality of health care. The purpose of this study was to compare the reliability, responsiveness, and efficiency of three PRO measures: the Foot and Ankle Ability Measure–Activity of Daily Living subscale (FAAM_ADL), the Foot Function Index 5-point verbal rating scale (FFI-5pt), and the PROMIS Physical Function computerized adaptive test (PF CAT).
Data were aggregated from 10 clinical sites in the AOFAS’s National Orthopaedic Foot and Ankle Research (OFAR) Network from 311 patients who underwent elective surgery for a disorder of the foot or ankle. Patients were administered the FAAM_ADL, FFI-5pt, and PF CAT at their preoperative visit and at 6 months after surgery. Reliabilities were evaluated using a Rasch model. Responsiveness was calculated using paired samples t test and efficiency was recorded as number of seconds to complete the instrument.
Similar reliabilities were found for the three instruments. Item reliabilities for FAAM_ADL, FFI-5pt, and PF CAT were all .99. Pearson reliabilities for FAAM_ADL, FFI-5pt, and PF CAT were .95, .93, and .96, respectively. On average, patients completed the FAAM_ADL in 179 seconds, the FFI-5pt in 194 seconds, and the PF CAT in 44 seconds, (P < .001). The PF CAT and FAAM_ADL showed significant improvement (P = .01 and P = .001, respectively) in patients’ physical function after treatment; the FFI-5pt did not show improvement.
Overall, the PF CAT performed best in terms of reliability, responsiveness, and efficiency in this broad sample of foot and ankle patients. It can be a potential replacement for the conventional PRO measures, but further validation is needed in conjunction with the PROMIS Pain instruments.
Level I, prospective comparative outcome study.
We investigated radiographic changes of calcaneocuboid (CC) joint subluxation following calcaneal lengthening procedure for the treatment of pediatric planovalgus foot deformities.
This study included 44 cases of planovalgus foot deformities in 24 patients with mean age of 9.7 (range, 8 to 13) years who underwent calcaneal lengthening between 1999 and 2011. The mean follow-up period was 25 (range, 12 to 159) months. Anteroposterior (AP) and lateral radiographs of the weight-bearing view of the foot from immediate postoperative, 3-month postoperative, and last follow-up evaluations were reviewed and also used for trend analysis. Percentage of CC joint subluxations was measured on both AP and lateral view of the foot. Correlations between the percentage of CC joint subluxation and follow-up periods were assessed.
All of the feet showed dorsal subluxation of their CC joint on the immediate postoperative lateral plain radiographs. The median percentage of dorsal subluxation of the CC joint improved from 26.0% (range, 10.0 to 67.0) at the immediate postoperative evaluation to 16.5% (range, 7.0 to 47.0, P = .0001) at the 3-month postoperative evaluation and to 11% (range, 2.0 to 30.0, P = .0003) at last follow-up. The trend analysis over time indicated that the CC joint subluxation percentage with calcaneal lengthening generally decreased over time (rs = –.67, P = .001). No patients showed osteoarthritic changes in the CC joint or nonunion at the calcaneal osteotomy site at last follow-up.
At midterm follow-up, the CC joint subluxation was gradually resolving over time, with no evidence of osteoarthritic change in the CC joint.
Level IV, case series.
Osteochondral lesions of the talar dome (OLT) involve the articular cartilage and/or subchondral bone. The subchondral bone plate plays an important role in cartilage metabolism. We hypothesized that the findings of subchondral bone on CT image would be related to the cartilage damage of OLT. The purpose of this study was to evaluate the relationship between the arthroscopic and CT findings focused on subchondral bone.
Thirty-one ankles diagnosed as OLT were analyzed. All patients underwent CT, MRI, and arthroscopic surgery. The CT findings for both the cystic and fragment lesions were classified into 3 types. The 3 types for the cystic lesion ankles were irregular shape, round shape with sclerotic wall, and irregular shape with opening to an articular cavity. The 3 types for the fragment lesion were no bone absorption, bed absorption without fragment absorption, and bed sclerosis and fragment absorption. The subchondral bone findings on CT were compared with International Cartilage Repair Society (ICRS) grades and arthroscopic grading.
All round and sclerotic cystic lesions revealed cartilaginous flap lesions with a nearly normal cartilage surface. An irregular shape with opening revealed an unstable lesion with severely damaged cartilage. As for fragment lesions, no absorption revealed a stable lesion with a nearly normal cartilage surface. Bed absorption revealed an unstable lesion with a nearly normal cartilage surface. Fragment absorption with bed sclerosis showed an unstable lesion with severely damaged cartilage. There was a significant difference between CT findings and ICRS grade or arthroscopic findings (both P < .01), while there was no significant difference with MRI grading. The diagnosis of cartilage status by CT was better than MRI.
CT findings for OLT based on subchondral bone related to cartilage damage. This study showed that CT was a useful tool for evaluating cartilage damage in OLT.
Level III, comparative case series.
Although functional and morbidity outcomes following ankle arthrodesis have been widely studied, patterns of health care resource utilization remain unclear. The purpose of this study was to identify preoperative and postoperative risk factors for nonroutine discharge following ankle arthrodesis. A secondary study aim was to determine risk factors associated with prolonged hospital stay.
Using the National Health Discharge Survey (NHDS) database for the years 2001 through 2007, an estimated 40 941 patients having undergone ankle arthrodesis were identified and separated into those who were discharged to home (routine discharge) and those who were discharged to rehabilitation facilities (nonroutine discharge). Factors influencing discharge disposition and hospital length of stay were determined using multivariable binary logistic regression analysis.
Risk factors for nonroutine discharge were increasing age, male sex, diabetes mellitus, atrial fibrillation, more than 1 general or surgery-related complication, additional days of care, and the 2005 to 2007 time period. Risk factors associated with prolonged hospital stay were advanced age, female sex, diabetes mellitus, more than 1 general or surgery-related complication, and the 2001 to 2004 time period.
Early identification of these factors might prove useful for better allocation of resources and implementation of effective strategies aimed at preventing longer hospitalizations and nonroutine discharges in selected patients at risk.
Level II, prognostic.
Several limited-open Achilles tendon repair techniques that use locking or nonlocking sutures have been developed, but direct comparisons of in vitro mechanical properties have not yet been reported in the literature. It was our hypothesis that loads applied to the repaired Achilles tendon would be better resisted by limited-open techniques that use locking stitches compared with limited-open repairs that use nonlocking stitches.
The Achilles tendons of 31 fresh-frozen cadaver lower limbs were incised 4 cm proximal to the calcaneal insertion. Tendons were then repaired using 1 of 2 limited-open Achilles tendon repair tools, one using 3 nonlocking sutures and the other using a combination of locking and nonlocking sutures. Repaired specimens were cycled to 1000 cycles from 20 to 100 N and from 20 to 190 N followed by a single load to failure test. Nonparametric analyses were performed to compare the number of cycles to gapping and total load to failure between the 2 repair techniques.
During cyclic loading, more cycles occurred prior to detection of 2-mm and 9.5-mm gaps in the locking suture construct compared with the nonlocking suture construct (P = .012 and P = .005, respectively). There was no difference in the number of cycles to a gap of 5 mm (P = .053). The locking suture construct also resisted a significantly greater load to failure compared with the nonlocking suture construct (P < .001; median 385.0 and 299.6 N, respectively).
Limited-open repair techniques using locking sutures provided greater construct strength under both cyclic and ultimate loads compared with a repair technique that used only nonlocking sutures.
Limited-open Achilles tendon repairs using locking sutures are better able to resist forces simulating early accelerated rehabilitation than repairs using nonlocking sutures.
Metatarsophalangeal joint (MPJ) instability, which often involves the second ray, may result in dorsal translation and coronal drift of the proximal phalanx, with subsequent crossover of the first and second toe. After traditionally described soft tissue and osteotomy procedures are used to treat this deformity, coronal plane malalignment may persist, but few additional surgical options have been described to address this problem.
We present a retrospective series of 5 patients who underwent a supplemental technique to augment coronal plane MPJ realignment. All patients underwent preplanned concomitant procedures. Crossover angulation of the second MPJ, amount of coronal translation required, and overall first-second ray alignment were compared pre- and postoperatively.
Depending on the severity of refractory deformity after soft tissue release and decompressive metatarsal osteotomy, 1.5 to 4.5 mm of coronal plane metatarsal head translation was required to achieve 3 to 20 degrees of overall valgus correction at the MPJ and complete correction of the crossover toe deformity. All patients were satisfied and had good function at last follow-up, a mean of 10.2 months, although 3 patients exhibited some level of second MPJ stiffness. One patient ended up with a component of residual floating toe deformity that was considered more of an incomplete correction of dorsal MPJ subluxation rather than any technical complication of this translational osteotomy modification designed to primarily correct coronal plane malalignment. A second patient had asymptomatic angular malalignment through partial (coronal plane) malrotation of the metatarsal osteotomy before it had healed.
We have found this technique modification to be a very effective and simple means of treating recalcitrant lesser MPJ coronal plane malalignment when traditional soft tissue and bony techniques fail to fully restore anatomic MPJ position.
Level IV, retrospective case series.
Injury to the tibiofibular syndesmosis is frequent with rotational ankle injuries. Multiple studies have shown a high rate of syndesmotic malreduction with the placement of syndesmotic screws. There are no studies evaluating the reduction or malreduction of the syndesmosis after syndesmotic screw removal. The purpose of this study was to prospectively evaluate syndesmotic reduction with CT scans and to determine the effect of screw removal on the malreduced syndesmosis.
This was an IRB-approved prospective radiographic study. Patients over 18 years of age treated at 1 institution between August 2008 and December 2011 with intraoperative evidence of syndesmotic disruption were enrolled. Postoperative CT scans were obtained of bilateral ankles within 2 weeks of operative fixation. Syndesmotic screws were removed after 3 months, and a second CT scan was then obtained 30 days after screw removal. Using axial CT images, syndesmotic reduction was evaluated compared to the contralateral uninjured ankle. Twenty-five patients were enrolled in this prospective study. The average age was 25.7 (range, 19 to 35), with 3 females and 22 males.
Nine patients (36%) had evidence of tibiofibular syndesmosis malreduction on their initial postoperative axial CT scans. In the postsyndesmosis screw removal CT scan, 8 of 9 or 89% of malreductions showed adequate reduction of the tibiofibular syndesmosis. There was a statistically significant reduction in syndesmotic malreductions (t = 3.333, P < .001) between the initial rate of malreduction after screw placement of 36% (9/25) and the rate of malreduction after all screws were removed of 4% (1/25).
Despite a high rate of initial malreduction (36%) after syndesmosis screw placement, 89% of the malreduced syndesmoses spontaneously reduced after screw removal. Syndesmotic screw removal may be advantageous to achieve final anatomic reduction of the distal tibiofibular joint, and we recommend it for the malreduced syndesmosis.
Level IV, prognostic case series.
Plantar fasciitis affects nearly 1 million people annually in the United States. Traditional nonoperative management is successful in about 90% of patients, usually within 10 months. Chronic plantar fasciitis develops in about 10% of patients and is a difficult clinical problem to treat. A newly emerging technology, low-level laser therapy (LLLT), has demonstrated promising results for the treatment of acute and chronic pain.
Thirty patients were administered LLLT and completed 12 months of follow-up. Patients were treated twice a week for 3 weeks for a total of 6 treatments and were evaluated at baseline, 2 weeks post procedure, and 6 and 12 months post procedure. Patients completed the Visual Analog Scale (VAS) and Foot Function Index (FFI) at study follow-up periods.
Patients demonstrated a mean improvement in heel pain VAS from 67.8 out of 100 at baseline to 6.9 out of 100 at the 12-month follow-up period. Total FFI score improved from a mean of 106.2 at baseline to 32.3 at 12 months post procedure.
Although further studies are warranted, this study shows that LLLT is a promising treatment of chronic plantar fasciitis.
Level 4, case series.
The standard treatment for hallux valgus in rheumatoid arthritis has been arthrodesis of the first metatarsophalangeal (MTP) joint. There is limited literature regarding the results of hallux valgus procedures which preserve the first MTP joint in rheumatoid patients. We investigated the radiographic and clinical outcomes of joint-preserving surgery for hallux valgus in a series of rheumatoid patients to evaluate the result of nonarthrodesis reconstruction.
Thirty-seven feet with hallux valgus in 27 patients with RA treated with a joint-preserving procedure of the first MTP joint were analyzed radiographically and clinically. Average follow-up was 42 (range, 12-111) months. Twenty feet had Ludloff osteotomies, 15 had scarf osteotomies, and 2 had chevron osteotomies. Radiographs were evaluated preoperatively and postoperatively for hallux valgus angle, 1-2 intermetatarsal angle, and degenerative narrowing of the first MTP joint based the Sharp score and the Larsen grade. Narrowing of the first interphalangeal (IP) joint was based on a modification of the classification of Hattrup and Johnson. Operative complications and required secondary surgeries were tabulated. Clinical outcomes were measured using preoperative and postoperative Short Form–36 (SF-36), AOFAS forefoot scale, and Visual Analogue Scale (VAS) pain questionnaires.
The average hallux valgus angle improved from 37 degrees preoperatively to 15 degrees postoperatively. The average 1-2 intermetatarsal angle improved from 14 degrees preoperatively to 5 degrees postoperatively. The average Sharp score of the first MTP joint was 0.9 preoperatively and 1.6 postoperatively. The average Larsen grade of the first MTP joint was 0.6 preoperatively and 1.4 postoperatively. Range of motion of the first MTP joint was essentially unchanged between preoperative and postoperative measurements. Seven of 37 feet had progression of first IP joint space narrowing, but none were symptomatic. The AOFAS score improved from 45.2 preoperatively to 82.6 at final follow-up (P value < .01). The VAS decreased from 4.8 preoperatively to 1.5 at final follow-up (P value < .02). The SF-36 physical component score decreased from 40.3 preoperatively to 37.4 at final follow-up, and the mental component score remained unchanged, and neither was statistically significant. There were 7 feet (19%) that required a return to surgery: 3 wound infections, 2 arthrodeses for progression of deformity, and 1 each for revision for recurrence and hardware removal.
Rheumatoid arthritis patients who undergo a bunionectomy rather than arthrodesis to preserve the first MTP joint have satisfactory clinical and radiographic outcomes. This procedure appeared to be a reasonable alternative to first MTP arthrodesis in patients with relatively preserved joints.
Level IV, retrospective case series.
Specialized treatment of plantar fasciitis that can reduce inflammation and promote healing may be a possible alternative prior to surgical intervention. We report the results of a randomized clinical trial examining the efficacy of micronized dehydrated human amniotic/chorionic membrane (mDHACM) injection as a treatment for chronic refractory plantar fasciitis.
An institutional review board–approved, prospective, randomized, single-center clinical trial was performed. Forty-five patients were randomized to receive injection of 2 cc 0.5% Marcaine plain, then either 1.25 cc saline (controls), 0.5 cc mDHACM, or 1.25 cc mDHACM. Follow-up visits occurred over 8 weeks to measure function, pain, and functional health and well-being.
Significant improvement in plantar fasciitis symptoms was observed in patients receiving 0.5 cc or 1.25 cc mDHACM versus controls within 1 week of treatment and throughout the study period. At 1 week, American Orthopaedic Foot and Ankle Society (AOFAS) Hindfoot scores increased by a mean of 2.2 ± 17.4 points for controls versus 38.7 ± 11.4 points for those receiving 0.5 cc mDHACM (P < .001) and 33.7 ± 14.0 points for those receiving 1.25 cc mDHACM (P < .001). By week 8 AOFAS Hindfoot scores increased by a mean of 12.9 ± 16.9 points for controls versus 51.6 ± 10.1 and 53.3 ± 9.4 for those receiving 0.5 cc and 1.25 cc mDHACM, respectively (both P < .001). No significant difference in treatment response was observed in patients receiving 0.5 cc versus 1.25 cc mDHACM.
In patients with refractory plantar fasciitis, mDHACM is a viable treatment option. Larger studies are needed to confirm our findings.
Level I, prospective randomized study.
Hallux valgus (HV) is frequently associated with other forefoot disorders, but its influence on preoperative quality of life (QOL) has not been well characterized. The main purpose of this study was to assess the influence of common associated forefoot disorders (metatarsalgia and lesser toe deformities) on preoperative QOL in patients with HV.
Preoperative QOL assessed through the Short Form–36 (SF-36, version 2) was obtained from 94 patients with HV from a database. Patients were classified according to their condition: HV alone, HV and metatarsalgia, HV and lesser toe deformities, and HV and both metatarsalgia and lesser toe deformities. Values of each domain were compared among groups. In addition, a correlational study between SF-36 and radiographic severity of HV was performed. The mean age of the 94 patients was 62.6 ± 12.3 years. There were 42.6% patients with HV alone, 30.8% with HV and metatarsalgia, 16% with HV and lesser toe deformities, and 10.6% with HV and both metatarsalgia and lesser toe deformities.
Patients with HV and associated metatarsalgia and lesser toe deformities had significantly worse physical function (P = .029), role-physical (P = .017), bodily pain (P = .045), role-emotional (P = .016), mental health (P = .001), and mental component summary (P = .003) compared to patients with HV alone. There were no significant correlations between radiographic HV and intermetatarsal angles and any of the domains or summaries of the SF-36.
Patients with HV and both metatarsalgia and lesser toe deformities have significantly worse QOL compared to patients with HV alone. The presence of associated forefoot deformities may be a discriminating factor for the prioritization of surgical treatment of HV.
Level III, cross-sectional study.
A cannulated lag screw inserted through the medial cuneiform into the base of the second metatarsal is often utilized to reduce the diastasis and aid healing of Lisfranc injuries. Also procedures such as a midfoot or a Lapidus arthrodesis require adequate implant-bone purchase in the medial cuneiform. The medial cuneiform contains cancellous bone of varying density. Knowledge of density variation may be helpful for implant usage and manufacturing of area specific implants.
In 60 randomly selected patients, mean computed tomography (CT) intensity in Hounsfield units was measured at 12 sampled locations within the medial cuneiform and served as a proxy for bone density. The patients’ age, gender, and race were recorded. An analysis of variance (ANOVA) assessed the effect of age, gender, race, and sample site on bone density. Statistical testing assumed 95% level of confidence.
ANOVA showed age, gender, and sample site had significant effects (P < .001) on bone density, though race had no significant effect (P = .28). The distal-dorsal-lateral (DDL) site was significantly denser than all other sites (P < .001) except the middle-dorsal-lateral (MDL) (P = .53). The proximal-plantar-lateral (PPL) site was significantly less dense than all other sites (P < .001) except the middle-plantar-lateral/medial and the proximal-plantar-medial sites (P < .14). A general trend of density increasing in the distal and dorsal directions was evident, and within the dorsal sites there was a trend of increasing density in the lateral direction.
This is the first study to date to measure density of the medial cuneiform using living subjects. The sample size of 60 patients was also the largest of any study measuring density of this bone. We conclude that the densest area of the medial cuneiform is the most anterior, dorsal, and lateral portion.
The findings of this study may indicate the most optimal area for implant purchase in the medial cuneiform when reducing the diastasis between the base of the second metatarsal and medial cuneiform and for stabilization of the medial column.
The concrete anatomy and functional characteristics of the subtalar ligaments have been a matter of debate that some believe has hampered the progress of clinical ligament reconstruction.
In 32 fresh-frozen cadaver feet, the course of the inferior extensor retinaculum (IER) and other subtalar ligaments was carefully measured and photographed both from the portal of the tarsal sinus and from a posterior view.
The IER inserted inside the tarsal sinus and canal by means of 3 roots: a lateral, an intermediate, and a medial one. These roots, along with the tarsal canal, divided the subtalar space into 3 parts. In front of the IER and inside the tarsal sinus, the thick cervical ligament (CL) lay at a 45-degree angle to the calcaneus. Behind the IER and inside the posterior capsule, in most cases (25 of 32 specimens), the posterior capsular ligament (PCaL) lay directly in front of the posterior talocalcaneal facet. Inside the tarsal canal, the fan-shaped medial root of the IER spread from outside upper lateral to lower medial, and the interosseous talocalcaneal ligament (ITCL) ran from upper medial to lower lateral; fibers of these 2 ligaments blended tightly together to form a V-shaped ligament complex. Just anterior to this complex in some cases (20 of 32 specimens), a short narrow upright ligament, the tarsal canal ligament (TCL), was located behind the middle talocalcaneal joint.
The results of this study show that the CL is the primary ligament in the tarsal sinus and that the ITCL is a thin single band rather than a strong bilaminar ligament located inside the tarsal canal. Instead, the medial root of the IER is the primary ligamentous structure in the tarsal canal.
The anatomical description provided here may provide a more accurate theoretical foundation for clinical subtalar stability restoration.
Nonoperative management has been the preferred treatment for displaced oblique spiral fractures of the fifth metatarsal shaft; yet a paucity of literature supports this claim. The purpose of this investigation was to report the incidence and long-term outcome in the largest cohort of these fractures reported to date.
From 2006 through 2010, 2990 patients sustaining closed metatarsal fractures were seen and treated. Displaced, oblique, spiral fractures of the distal shaft of the fifth metatarsal were identified and follow-up was conducted. Only patients who were initially treated with nonoperative management were included. Patients were seen at 6 and 12 weeks, and a minimum 2-year follow-up was conducted. In addition, demographic information was obtained, and the Short Form–12 (SF-12) and Foot and Ankle Ability Measure (FAAM) were administered. Average follow-up was 3.5 years.
In all, 142 acute fractures were managed for an incidence of 4.8% of all metatarsal fractures. There were 117 females and 25 males, average age was 55. FAAM activities of daily living subscale scores averaged 95.5 (±5.7), while FAAM sports subscales were 92.7 (±9.1). SF-12 physical and mental scores averaged 51.4 (±4.9) and 50.3 (±4.6), respectively. There were 2 delayed unions, 1 asymptomatic nonunion treated nonoperatively, and 2 painful nonunions that required open reduction internal fixation with bone grafting.
This large cohort described the relative incidence and functional outcomes of displaced oblique fracture of shaft of the fifth metatarsal bone treated nonoperatively. Nonoperative management of these fractures resulted in excellent, long-term functional outcomes.
Level II, prospective cohort study.
Protected elevation represents a critical component of postoperative care, particularly in posteriorly located flaps, to prevent pressure on the flap’s vascular pedicle and ensure a successful skin graft. Although several short case series and technique papers have described kickstand placement to prevent heel ulcers as an adjuvant to fixator placement for fracture management, there remains a paucity of reports describing external fixator placement solely for extremity elevation and pressure alleviation in the postoperative care of flap coverage procedures.
Patients who underwent lower extremity free flap coverage procedures requiring temporary elevation were included. Age, diagnosis, soft tissue procedures performed, type of external fixator placed, duration of frame placement, mode of removal, and complications related to external fixator placement were documented. Patients requiring external fixator placement for fracture management were excluded.
Twelve patients with 13 lower limb soft tissue defects were included in our case series. A thin-wire ring external fixator kickstand was applied in 5 limbs while the rest underwent placement of a uniplanar carbon fiber bar type external fixator kickstands. The average time for removal of the frames was 4 weeks. No complications were reported from kickstand placement.
The use of external fixator kickstands is an effective and safe adjuvant to soft tissue flap procedures for the lower extremity. Our case series is the largest in the literature and first to address the technical considerations for frame placement, positioning, and removal for external fixator kickstands placed solely for flap coverage procedures.
Level IV, retrospective case series.
Diabetic peripheral neuropathy is now well recognized as the most common cause of Charcot arthropathy of the foot and ankle, but it may be associated with other peripheral neuropathies. While not well known, it is well documented that rheumatoid arthritis is correlated with peripheral neuropathy. However, despite rheumatoid neuropathy, Charcot arthropathy has never been associated with rheumatoid arthritis. We report a series of Charcot arthropathy patients with concomitant rheumatoid arthritis.
The medical records of patients treated between 1986 and 2009 with Charcot arthropathy and rheumatoid arthritis were reviewed. Recorded data included neuropathy risk factors, medications, history of ulcerations, ambulatory status, shoe wear, and treatment course. Radiographs of Charcot joints were categorized according to the Brodsky anatomic classification. Patient care was based on published treatment algorithms, emphasizing accommodative, nonoperative treatment with selective surgical interventions. Surgery was indicated for recalcitrant, nonhealing lesions of the soft tissue and/or unbraceable, nonplantigrade feet. A successful outcome was considered an ambulatory patient without amputation and a closed skin envelope at last follow-up.
Four men and 16 women met the diagnostic criteria, resulting in 33 feet in the series. Average age was 61 years, and average follow-up was 4.3 years. In addition to rheumatoid arthritis, 4 patients (7 feet) had hypothyroidism, 4 patients (6 feet) had diabetes, 1 patient (2 feet) had megaloblastic anemia and diabetes, and 1 patient (1 foot) had hypothyroidism and diabetes; however, 17 feet (52%) had no known sources for neuropathy. Charcot involvement was type 1–midfoot in 21 feet (64%), type 2–hindfoot in 7 (21%), type 3a–ankle in 4 (12%), and type 3b–calcaneus in 1 (3%). Twenty-three feet (70%) were treated with conservative modalities. Ten feet (30%) required 15 surgeries, of which an exostectomy was the most common procedure. Of the 33 feet, 3 had persistent ulcerations and 1 underwent major amputation, representing 4 failures.
Raising awareness within the orthopaedic community, we report a Charcot arthropathy population with a concomitant rheumatoid arthritis diagnosis, emphasizing a relationship between the 2 diseases. Through a conservative treatment regimen combined with selective surgical interventions, satisfactory outcomes were achieved in 88% of the rheumatoid Charcot feet. While several patients had additional neuropathy sources which could cause Charcot arthropathy (eg, diabetes), the majority of feet had no etiologies accounting for neuropathy or neuroarthropathy except rheumatoid arthritis. Further study is required to expand on this relationship between the 2 diseases.
Level IV, retrospective case series.
A fixed cavovarus foot deformity can be associated with anteromedial ankle arthrosis due to elevated medial joint contact stresses. Supramalleolar valgus osteotomies (SMOT) and lateralizing calcaneal osteotomies (LCOT) are commonly used to treat symptoms by redistributing joint contact forces. In a cavovarus model, the effects of SMOT and LCOT on the lateralization of the center of force (COF) and reduction of the peak pressure in the ankle joint were compared.
A previously published cavovarus model with fixed hindfoot varus was simulated in 10 cadaver specimens. Closing wedge supramalleolar valgus osteotomies 3 cm above the ankle joint level (6 and 11 degrees) and lateral sliding calcaneal osteotomies (5 and 10 mm displacement) were analyzed at 300 N axial static load (half body weight). The COF migration and peak pressure decrease in the ankle were recorded using high-resolution TekScan pressure sensors.
A significant lateral COF shift was observed for each osteotomy: 2.1 mm for the 6 degrees (P = .014) and 2.3 mm for the 11 degrees SMOT (P = .010). The 5 mm LCOT led to a lateral shift of 2.0 mm (P = .042) and the 10 mm LCOT to a shift of 3.0 mm (P = .006). Comparing the different osteotomies among themselves no significant differences were recorded. No significant anteroposterior COF shift was seen. A significant peak pressure reduction was recorded for each osteotomy: The SMOT led to a reduction of 29% (P = .033) for the 6 degrees and 47% (P = .003) for the 11 degrees osteotomy, and the LCOT to a reduction of 41% (P = .003) for the 5 mm and 49% (P = .002) for the 10 mm osteotomy. Similar to the COF lateralization no significant differences between the osteotomies were seen.
LCOT and SMOT significantly reduced anteromedial ankle joint contact stresses in this cavovarus model. The unloading effects of both osteotomies were equivalent. More correction did not lead to significantly more lateralization of the COF or more reduction of peak pressure but a trend was seen.
In patients with fixed cavovarus feet, both SMOT and LCOT provided equally good redistribution of elevated ankle joint contact forces. Increasing the amount of displacement did not seem to equally improve the joint pressures. The site of osteotomy could therefore be chosen on the basis of surgeon’s preference, simplicity, or local factors in case of more complex reconstructions.
Among the various operative treatments of Morton’s neuroma, deep transverse metatarsal ligament (DTML) release has been performed for decompression of neuroma. However, the main lesion of Morton’s neuroma is located between the metatarsal head and the metatarsophalangeal (MTP) joint and more distal than the DTML. Hence we performed the metatarsal shortening osteotomy along with DTML release for decompression of neuroma, and investigated the clinical outcomes of it and compared the outcomes with those of DTML release alone.
We retrospectively reviewed 84 consecutive patients (86 neuromas) who underwent surgery for a Morton’s neuroma between February 2008 and March 2011. The first 46 neuroma (group A) were treated with DTML release alone, and the next 40 neuroma (group B) underwent the metatarsal shortening osteotomy with DTML release. Clinical outcomes were compared between the groups and the associations between clinical outcomes and neuroma size were assessed.
Clinical outcomes were significantly improved after surgery in both groups but there were significant differences in clinical outcomes between the 2 groups at final follow-up. There were significant correlations between neuroma size and outcomes in group A, whereas no significant correlations were found between neuroma size and outcomes in group B.
The metatarsal shortening osteotomy with DTML release resulted in better outcomes compared with DTML release alone in patients with Morton’s neuromas.
Level III, retrospective comparative series.
Although metatarsophalangeal (MTP) arthrodesis has been advocated by many authors, implant arthroplasty appears to be successful option in advanced hallux rigidus (HR). The aim of our study was to evaluate the early results of the ToeFit-Plus prosthesis for the treatment of HR.
Between December 2007 and January 2011, a total of 26 toes of 24 patients with MTP arthritis of the great toe were treated with ToeFit-Plus implant. The average follow-up time was 29.9 (range: 25 to 62) months. All patients were evaluated clinically and radiographically. Postoperative satisfaction and function were scored according to the American Orthopaedic Foot and Ankle Society (AOFAS) score. Pain was assessed with the use of a visual analogue scale.
Mean preoperative AOFAS score improved from 42.7 (range: 36 to 59) to 88.5 (range: 59 to 98) at the final follow-up (P < .01). Preoperative average visual analogue scale pain scores improved from 7.4 preoperatively to 1.9 at the final follow-up (P < .01). The average MTP joint range of motion improved from 25.9 degrees preoperatively to 53.8 degrees at the final follow-up. No radiologic loosening was found, but radiolucency was observed in 2 patients with this implant. No revision was required for any of the patients during the follow-up period.
This total first MTP joint prosthesis yielded good functional outcome and high patient satisfaction level with low early complication rate. Preservation of joint movement and good pain relief with early mobilization were the advantages of this procedure. Salvage arthrodesis remains an option if future revisions are indicated.
Level IV, retrospective case series.
The proximal oblique sliding closing wedge osteotomy (POSCOW) technique was developed to address moderate to severe hallux valgus deformity. We present a retrospective multicenter study to analyze the midterm radiological and clinical outcomes of patients treated with this type of proximal osteotomy fixed with plates.
One hundred and forty-four patients (187 feet) were operated on between May 2005 and June 2010 in 2 separate centers. Inclusion criteria were symptomatic moderate to severe incongruent hallux valgus deformity, no significant restriction in the first metatarsophalangeal joint movement, none to minimal degenerative changes in the first metatarsophalangeal or the tarsometatarsal joints, and no hypermobility. The median age was 60 years. The preoperative hallux valgus angle (HV) was 35.6 degrees, intermetatarsal angle (IM) was 15.3 degrees, AOFAS score was 53 points. The median follow-up was 35 months (range, 12-73). A POSCOW osteotomy was performed in all patients and fixed with plates. We recorded the satisfaction rate, postoperative clinical and radiological results, and complications.
The patient satisfaction rate was 87%. The mean postoperative HV angle was 12.3 degrees, IM angle 4.8 degrees, AOFAS score 89 points. The mean decrease in the first metatarsal length was 2.2 mm (range, 0-8). Twelve feet (6.4%) with recurrence of the deformity required revision surgeries. Removal of complete or partial hardware was needed in 23 feet (12.3%) for symptomatic hardware. Five feet (2.6%) developed hallux varus but only 2 required surgery. Transfer metatarsalgia was noted in 9 feet (4.8%).
The POSCOW osteotomy was an effective and reliable method for relieving pain and improving function. A learning curve was present, as most of the complications happened in the initial cases. To our knowledge, this is the largest reported series of proximal closing wedge osteotomy for hallux valgus deformities.
Level IV, case series.
Realignment surgeries for mild to moderate ankle osteoarthritis with minimal talar tilt have been reported to be effective. However, there has been no report on joint-sparing surgery of ankle osteoarthritis in patients with paralytic disorders who have severe talar tilt. We therefore investigated whether ankle osteoarthritis with severe talar tilt caused by paralytic disorders can be improved after operative treatment.
This study included 12 ankles (11 patients) with varus ankle osteoarthritis from paralytic disorders with cavovarus deformity of the foot. Mean follow-up period was 3.0 years (range, 2-4.5 years). Causes of paralysis were residual polio in 7 ankles (6 patients), cerebral palsy in 2 ankles, and idiopathic in 3 ankles. Preoperative and postoperative clinical assessments were performed using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score and a visual analogue scale (VAS). The Ankle Osteoarthritis Scale (AOS) was used for postoperative assessment. Pre- and postoperative radiographic parameters were compared.
Mean AOFAS score improved from 39.1 (range, 32-57) preoperatively to 77.9 (range, 72-85) postoperatively. Mean talar tilt improved from 17.4 degrees (range, 9.5-33.5 degrees) to 1.4 degrees (range, 0-4 degrees). Degree of osteoarthritis according to Takakura classification improved in all ankles except two. Mean heel alignment angle was reduced from 40.4 degrees (range, 2-65 degrees) of varus preoperatively to 11.2 degrees (range, –3 to 25.5 degrees) of varus postoperatively.
Medial varus ankle osteoarthritis from paralytic cavovarus may be improved even in cases of severe talar tilt.
Level IV, retrospective case series.
The Kellgren and Lawrence grading system (KLGS) has been used throughout the literature for the radiographic staging of osteoarthritis (OA) of the peritalar joints. Despite its widespread use, the KLGS has never been validated for use in this clinical circumstance. The purpose of this study was to determine the inter- and intrarater reliability of the KLGS in the assessment of radiographic progression of OA in the peritalar joints following total ankle replacement (TAR).
One hundred twenty pre- and minimum 5-year postoperative weight-bearing lateral radiographs following 60 consecutive cases of TAR were utilized. Each individual film was considered separately for the purposes of this study. Of those films, 93 and 98 were found to have adequate visualization of the subtalar (STJ) and talonavicular (TNJ) joints, respectively. Three qualified reviewers graded the films according to the KLGS on 2 separate occasions, with 1 month separating the 2 readings. The results were analyzed for intra- and interobserver reliability. The degree of agreement was analyzed using the weighted kappa (w) statistic, Fleiss’s kappa (Fleiss’s ), and percentage agreement
Interrater agreements were moderate (w = 0.37 ± 0.06; Fleiss’s = 0.21 ± 0.03) for the STJ to fair (w = 0.43 ± 0.06; Fleiss’s = 0.25 ± 0.03) for the TNJ. Intrarater agreements for the STJ were moderate (mean w = 0.43 ± 0.07) and moderate for the TNJ as well (mean w = 0.46 ± 0.07). The reliability of the KLGS, although not originally designed for use in the setting of inflammatory arthropathy, was not notably affected when being used to grade inflammatory versus noninflammatory arthropathy.
The KLGS is likely not a reliable tool for grading the degree of OA present in the peritalar joints prior to treatment and following TAR for research purposes. Using the KLGS in the setting of inflammatory arthritis versus OA did not produce any notable differences in the observed reliability. It is important to remember this has not been assessed in the clinical environment. Further work is required to determine the optimal method for assessment of peritalar OA.
Multimodal postoperative analgesia employs multiple medications given perioperatively to block the generation and perception of pain at different points in the nociceptive pathway. This retrospective study examines its effect on the length of stay for patients undergoing hindfoot and ankle fusions.
All patients operated upon by the senior authors between 2007 and 2011, inclusive, underwent ankle fusion, subtalar fusion, pantalar arthrodesis, triple arthrodesis, or combined ankle/subtalar fusions. The perioperative pain management was either the "traditional" method (patient-controlled-analgesia–delivered parenteral narcotics beginning immediately postoperatively) or the multimodal pain protocol (pre- and postoperative oral administration of opioids, celecoxib, pregabalin, acetaminophen, and prednisone). The choice of pain protocol was up to the surgeons, without any exclusion criteria. Physical therapy protocols were not changed during the study. The study included 220 patients; 175 received the multimodal protocol and 45 received traditional management. Multimodal protocol patients were younger (53.9 vs 59.7 years; P < .003), but there were no other differences between the groups with respect to gender, obesity, body mass index, tobacco use, alcohol use, or comorbidities. Complex cases (revision surgeries, Charcot joint surgeries, multiple concurrent procedures, etc) were equally represented in both groups.
Multimodal protocol patients had lower lengths of stay (2.5 days; 95% confidence interval [CI], 1.4-3.7) than traditional pain management patients (4.2 days; 95% CI, 2.7-5.7; P < .001). This was also true for both complicated and uncomplicated surgeries when considered separately.
This study provides the first evidence that multimodal therapy reduces the length of stay for patients undergoing major hindfoot or ankle fusion surgery, regardless of surgical complexity.
The literature supports fusion as the surgical treatment of choice for stage III posterior tibial tendon dysfunction (PTTD). The present study reports the radiographic correction following a modified triple arthrodesis (fusions of the subtalar, talonavicular, and first tarsometatarsal joints) in patients with stage III PTTD.
An institutional review board–approved retrospective study was performed to assess the radiographic outcome of a modified triple arthrodesis in 21 patients (22 feet). Pre- and postoperative weight-bearing radiographs were reviewed in a blinded fashion by clinicians of varying levels of training. The talo–first metatarsal, talocalcaneal, and talonavicular coverage angles were measured on anteroposterior views. On lateral views, the talo–first metatarsal (Meary’s), talocalcaneal, calcaneal pitch, and talar declination angles and the medial cuneiform to floor distance were measured. Statistical analysis was performed to compare pre- and postoperative measurements, assess the degree of correction, and determine interobserver reliability of the radiographic measurements.
All measurements improved significantly after treatment with a modified triple arthrodesis (P ≤ .001). The medial cuneiform to floor distance (0.910), talonavicular coverage angle (0.896), and lateral talo–first metatarsal angle (0.873) were the most reproducible between observers. Postoperatively, 100% of feet were corrected to normal medial cuneiform to floor distance and talonavicular coverage angle, and 90.9% were corrected to a normal lateral talo–first metatarsal angle.
The modified triple arthrodesis resulted in a reliable and reproducible correction of the deformity seen in rigid stage III PTTD.
Level IV, case series.
The purpose of this study was to evaluate the functional outcome as measured by prospective gait analysis of patients undergoing total ankle arthroplasty using a 2-component Salto Talaris total ankle prostheses with a fixed polyethylene bearing.
Twenty-one patients with severe ankle arthritis who underwent unilateral total ankle arthroplasty using a 2-component Salto Talaris device with a fixed polyethylene bearing were studied prospectively. Mean age was 69 years in 16 female and 5 male patients, and mean follow-up was 37.2 (range, 24-50) months. Three-dimensional gait analysis was performed using a 12-camera digital-motion capture system preoperatively and repeated at a minimum of 2 years postoperatively. Temporospatial measurements included velocity, cadence, step length, and support times. Measured kinematic parameters included sagittal plane range of motion of the ankle, knee, and hip. Kinetic parameters included sagittal plane ankle power and ankle plantarflexion moment.
There was significant improvement in temporospatial parameters, including step length (P = .014) and walking velocity, which increased from 0.9 to 1 m/s (P = .01). Kinematic results showed sagittal plane range of motion of the ankle increased significantly from a mean of 15.8 degrees preoperatively to 20.6 degrees (P = .00005) postoperatively with the increase occurring primarily in dorsiflexion. Kinetic results showed ankle peak power increased from a mean of 0.7 Nm/kg to 1.1 Nm/kg (P = .004).
A prospective study of gait in patients undergoing total ankle arthroplasty using a 2-component Salto Talaris device with a fixed polyethylene bearing showed, at midterm follow-up, significant improvements in multiple parameters of gait when compared to the patients’ own preoperative function.
Level IV, prospective case series.
Displaced lateral malleolar fractures are often treated with reduction and surgical stabilization. However, there has not been a comprehensive laboratory comparison to determine the most appropriate device for treating these patients. This study subjected a range of contemporary lateral fibular plates to a series of mechanical tests designed to reveal performance differences.
Forty fresh frozen lower extremities were divided into 4 groups. A Weber B distal fibula fracture was simulated with an osteotomy and stabilized using 1 of 4 plate systems: a standard Synthes one-third tubular plate with interfragmentary lag screw, a Synthes LCP locking plate with lag screw, an Orthohelix MaxLock Extreme low-profile locking plate with lag screw, or a TriMed Sidewinder nonlocking plate. Controlled monotonic bending and cyclic torsional loading were applied and bending stiffness, torsional stiffness, and fracture site motion were quantified. Resistance to cyclic torsional loading was determined by quantifying the number of loads withstood before excessive rotation occurred. Correlation between bone mineral density and each of the mechanical measures was determined.
There was no difference in angulation or bending stiffness between plates. All plates except the LCP showed greater lateral deflection than in the other bending directions. Bending stiffness was lowest in lateral distal fragment deflection for all 4 plates. There was a positive correlation between bone mineral density and bending stiffness for all plate types. There was no difference in fracture site rotation between plate types in internal or external torsion, but internal rotation of the distal fragment consistently exceeded external rotation. Torsional stiffness in external rotation exceeded stiffness in internal rotation in nearly all specimens. LCP plates performed relatively poorly under cyclic torsion.
Significant differences in plate performance were not demonstrated. The effects of bone quality variability and differences in interfragmentary screw purchase resulted in data dispersion that confounded absolute ranking of plate performance.
Identification of an optimal lateral fibular plating system has the potential to improve the clinical outcome of malleolar fracture fixation, particularly when patient conditions are unfavorable.
Avascular necrosis (AVN) or persistent nonunion occurs in situations of poor vascular supply. Some specific situations that plague the foot and ankle surgeon are talus nonunion, talus AVN, navicular AVN, and failed ankle arthrodesis with bone loss. The medial femoral condyle (MFC) flap has emerged as a popular source of vascularized corticocancelous bone. We present a series of cases demonstrating the versatility of the MFC flap in complex foot and ankle pathology.
A retrospective review was completed of all MFC flaps used in the foot and ankle over the past 5 years. Five patients were identified (average age 48). Surgical indications included talar AVN and ankle arthritis, talar nonunion, and navicular AVN. All patients had undergone conventional bone grafting techniques, which failed, prior to being treated with a MFC free flap; this series of patients did not possess significant medical comorbidities. Fixation techniques included compression screw fixation, plate osteosynthesis, or fine wire external fixation. The average follow-up was 20 months (range 8 to 40 months).
There was a 100% flap success rate with no returns to the operating room for thrombosis. The volume of the bone flaps was 5.6 cm3 (range 1 cm3 to 12 cm3). The average follow-up time was 20 months (range 8 to 40 months). All cases resulted in union, and full weight bearing status was achieved at a mean of 23.8 weeks (range 10 to 52 weeks) postoperatively.
Vascularized bone transfer in the form of the MFC free flap was a valuable method for foot and ankle reconstruction. The MFC flap provided an alternative for those defects that were smaller then 3 cm in length. In our experience, for small bone defects requiring vascularized bone, the MFC flap is currently the ideal donor location supplanting the iliac crest.
Level IV, retrospective case series.
Many techniques have been described for arthrodesis of the first metatarsophalangeal (MTP) joint. The purpose of this study was to determine the results of fixation using a low-profile dorsal titanium plate with locking screws in the phalanx, nonlocking screws in the metatarsal, and a plantar neutralization screw.
Forty-nine consecutive patients (51 feet) underwent a first MTP joint arthrodesis during an enrollment period of 1 year from October 2010 to November, 2011. All patients were evaluated preoperatively for primary pathology, pain, function, radiographic findings, AOFAS scores, and physical exam findings. First MTP joint arthrodesis was performed with a precontoured dorsal titanium plate with preset valgus and dorsiflexion after the joint surfaces were prepared with dome-shaped power reamers to achieve congruous cancellous bone surfaces. At a minimum of 1-year follow-up, patients returned for postoperative evaluation of pain, function, radiographic findings, satisfaction, AOFAS scores, and physical exam findings.
Forty-six of 49 (48 feet) patients returned for final follow-up examination at least 12 months after operative intervention. Forty-one patients (89%) reported good to excellent results. Visual analog pain scores improved from an average of 6.6 preoperatively to an average of 1.6 postoperatively (t = –9.3339, df = 45, P < .001). Functional capacity scores improved from a preoperative mean of 2.5 to a postoperative mean of 1.4 (t = –5.2648, df = 46, P < .001). AOFAS hallux MTP joint scores improved from a preoperative mean of 45 to a postoperative mean of 77 (t = 9.9498, df = 46, P < .003). Eighteen of 48 great toes (38%) had preoperative pronation whereas, 2 of 48 great toes (4%) had postoperative pronation. Eleven of 46 patients (24%) were unable to perform preoperative toe rise, and 8 of 46 (17%) were unable to perform postoperative toe rise. Twenty-five of 46 patients (54%) had gait improvement, while 19 patients (44%) had no change in gait, and 2 patients (4%) had gait deterioration. The mean preoperative hallux valgus angle of 27 degrees improved to a mean postoperative angle of 13 degrees (t = –6.1982, df = 46, P < .001). The mean preoperative 1-2 intermetatarsal angle of 12 degrees improved to a mean postoperative angle of 9 degrees (t = –5.2614, df = 46, P < .001). There was 1 delayed union (2%) and 1 nonunion (2%).
Our outcome scores indicate that first MTP joint arthrodesis with a precontoured dorsal titanium plate with locking screws in the phalanx and nonlocking screws in the first metatarsal is both reliable and reproducible with a very high bony union rate.
Level IV, prospective case series.
The flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendon are routinely used in reconstructive foot and ankle surgery. The tendons cross in the chiasma plantare and show variable interconnections. This can complicate harvesting of the tendons. Previous anatomical studies were inconclusive and did not reference the connections to surgically relevant landmarks. The purpose of this study was to integrate these conflicting results, introduce a thorough classification system, and analyze the position of the interconnections relative to the surgically relevant bone landmarks.
Sixty embalmed feet of 30 cadavers were analyzed anatomically with respect to the individual cross-links in the planta pedis. All feet were photo documented. The interconnections were classified in a modified classification system and distances to surgically relevant anatomic landmarks measured.
A proximal to distal connection from the FHL to the FDL was found in 95% of the feet (types I and III), in 3% there was a proximal to distal connection from the FDL to the FHL (type II) tendon only, and in 30% a crossed connection (type III) was found. The average point of branching of the FHL and FDL tendon was 5.3 and 4.6 cm distal to the medial malleolus, respectively.
Our modified classification system accommodated all found variations. In over 90% of the feet, a proximal to distal connection from the FHL to the FDL was found, which might contribute to the residual function of the lesser toes after FDL transfer.
The exact knowledge of the anatomy of the crossing of FDL and FHL in the plantar foot is essential to facilitate tendon harvesting, reduce morbidity and explain possible postoperative functional loss.
In Chopart-level amputations the heel often deviates into equinus and varus when, due to the lack of healthy anterior soft tissue, rebalancing tendon transfers to the talar head are not possible. Consequently, anterior and lateral wound dehiscence and ulceration may occur requiring higher-level amputation to achieve wound closure, with considerable loss of function for the patients.
Twenty-four consecutive patients (15 diabetes, 6 trauma, and 3 tumor) had Chopart’s amputation and simultaneous or delayed additional ankle dorsiflexion arthrodesis to allow for tension-free wound closure or soft tissue reconstruction, or to treat secondary recurrent ulcerations. Percutaneous Achilles tendon lengthening and subtalar arthrodesis were added as needed. Wound healing problems, time to fusion and full weight-bearing in the prosthesis, complications in the prosthesis, and the ambulatory status were assessed. Satisfaction and function were evaluated by the AmpuPro score and the validated Prosthesis Evaluation Questionnaire scale.
Five patients had successful soft tissue healing and fusions but died of their underlying disease 2 to 46 months after the operation. Two diabetic patients required a transtibial amputation. The other 17 patients were followed for 27 months (range, 13-63). The average age of the 4 women and 13 men was 53.9 years (range, 16-87). Postoperative complications included minor wound healing problems in 8 patients, wound breakdown requiring revision in 4, phantom pain in 3, residual equinus in 1, and adjacent scar carcinoma in 1 patient. The time to full weight-bearing in the prosthesis ranged from 6 to 24 weeks (mean 10). The mean AmpuPro score was 107 points (of 120), and the mean Prosthesis Evaluation Questionnaire scale was 147 points (of 200). No complications occurred with the prosthesis. Twelve patients lost 1 to 2 mobility classes (mean 0.9). The arthrodeses all healed within 2.5 months (range, 1.5 to 5 months).
Adding an ankle arthrodesis to a Chopart’s amputation either immediately or in a delayed fashion to treat anterior soft tissue complications was a successful salvage in most patients at this amputation level. It enabled the patients to preserve the advantages of a full-length limb with terminal weight-bearing.
Level IV, retrospective case series.
Disruption of the plantar plate of the lesser metatarsophalangeal (MTP) joints leads to significant instability. Despite the fact that plantar plate disorders are common, the best mode of treatment remains controversial with operative treatments having variable and somewhat unpredictable clinical outcomes.
Lesser MTP joints from the second, third, and fourth toes from fresh-frozen cadaver feet were biomechanically tested: (1) intact, (2) with the plantar plate disrupted, and (3) following a Weil osteotomy, a flexor-to-extensor tendon transfer, or a Weil osteotomy with a subsequent flexor-to-extensor tendon transfer with testing in superior subluxation, dorsiflexion, and plantarflexion.
The plantar plate significantly contributed to stabilizing the sagittal plane of the lesser MTP joints. The flexor-to-extensor tendon transfer significantly stabilized the disrupted lesser MTP joints in both superior subluxation and in dorsiflexion. The flexor-to-extensor tendon transfer following a Weil osteotomy also significantly stabilized the disrupted lesser MTP joints in both superior subluxation and in dorsiflexion.
In this cadaver-based experiment, disruption of the plantar plate of the lesser MTP joints led to significant instability. After plantar plate disruption, the Weil osteotomy left the joint unstable. The flexor-to-extensor tendon transfer by itself increased the stability of the joint in dorsiflexion, but combined with a Weil osteotomy restored near intact stability against superior subluxation and dorsiflexion forces.
Surgeons using the Weil osteotomy for plantar plate deficient MTP joints may consider adding a flexor tendon transfer to the procedure. Techniques to repair the torn plantar plate directly are needed.
One of the rationales for total ankle arthroplasty (TAA) is that it may retard the changes of hypermobility and accelerated arthritis in the hindfoot after ankle arthrodesis. Until recently, it has not been possible to quantify or even objectively demonstrate biomechanical findings to substantiate the theory that postsurgical biomechanical changes in the ankle produce changes in the kinematics of the hindfoot. Standard gait analysis has treated the foot as a single biomechanical unit. This study was undertaken to describe the hindfoot motion following Scandinavian Total Ankle Replacement (STAR) TAA by using multisegment foot model gait analysis.
Forty-six patients with a mean age of 66 years underwent a 3D gait analysis following TAR. Mean interval between surgery and gait analysis was 4.9 years (range 2 to 9). The contralateral limb was used as control for each patient. Temporospatial variables and kinematic parameters were studied.
Temporospatial results showed statistically significant differences. Stance time on the affected side was 61.1% ± 2.2% of the gait cycle compared to 63.2% ± 2.1% for the unaffected side. Step length was 55.6 cm ± 10 on the affected side compared to 53.9 cm ± 10 for the unaffected side. Kinematics results were statistically significant: Ankle range of motion (ROM) on the arthroplasty side was 16.8 ± 4.5 degrees compared to 23.6 ± 5.0 on the unaffected side. Sagittal plane ROM was 12.7 ± 4.2 degrees on the arthroplasty side and 17.3 ± 3.5 degrees on the unaffected side. Coronal plane ROM was 4.7 ± 2.4 degrees on the arthroplasty side and 7.5 ± 2.4 degrees on the unaffected side. Transverse plane ROM on the arthroplasty side was 4.1 ± 1.5 degrees and 4.9 ± 1.6 on the unaffected side.
This study showed that, in addition to previously documented diminution in sagittal plane motion and gait velocity, some of the residual abnormalities of gait following TAR were comprised of differences in hindfoot function. These results relate to the growing recognition of the importance of understanding hindfoot mechanics apart from those of the tibiotalar joint.
Level III, comparative case series.
Although tibiotalar fusion has historically been considered the gold standard treatment for end-stage arthritis of the ankle, the performance of total ankle replacement appears to be gaining favor as improved outcomes have been observed with new implant designs and surgical techniques. The purpose of this study was to compare trends and demographics in the performance of ankle fusion and total ankle replacement in the United States.
The Current Procedural Terminology (CPT) codes of patients undergoing ankle fusion and total ankle replacement were searched using the PearlDiver Patient Record Database, a national database of orthopaedic patients. The CPT codes for open ankle arthrodesis (27870), arthroscopic ankle arthrodesis (29899), and total ankle replacement (27700, 27702) were searched for the years 2004 to 2009 to identify relative changes in the performance of ankle fusion and replacement over time.
The performance of ankle fusion was unchanged during the 6-year study period. In contrast, an increase in total ankle replacement was observed, from 0.63 cases per 10 000 patients searched in 2004 to 0.99 cases per 10 000 patients in 2009 (P < .05). Both ankle fusion and total ankle replacement were performed most commonly in patients aged 60 to 69 years (P < .05). Although an even gender distribution was observed in patients undergoing total ankle replacement, open and arthroscopic fusion were more commonly performed in males (P < .05). With regard to regional distribution, open and arthroscopic fusion were most commonly performed in the western region of the United States, whereas total ankle replacement was performed most frequently in the Midwest (P < .001).
In the population studied, the performance of total ankle replacement increased 57% from 2004 to 2009 and was performed equally in male and female patients when compared to ankle fusion, which was more often performed in males and was unchanged with time.
Level IV, cross-sectional study.
Current operative treatment options for chronic lateral ankle instability include anatomic repairs utilizing existing local tissue and nonanatomic reconstructions sacrificing the peroneus brevis tendon to mechanically stabilize the ankle. Recent studies have modified these techniques to create an anatomic reconstruction utilizing allograft tendons. The purpose of this study was to retrospectively examine the clinical outcomes of a near-anatomic ligament reconstruction utilizing an allograft tendon for recurrent or complex lateral ankle instability.
Twenty-eight patients underwent a near-anatomic allograft lateral ankle ligament reconstruction with a semitendinosis allograft for severe or recurrent lateral ankle ligamentous instability, and all of them were available for follow-up at an average 32 months. Twelve patients had previously undergone lateral ankle ligament stabilizing surgery, 4 had Ehlers Danlos syndrome with poor local tissue, 5 had greater than 30 degrees of varus angulation of talar tilt, while 12 had associated hindfoot varus requiring concomitant reconstruction. Patients were assessed pre- and postoperatively for Visual Analog Scores (VAS) for pain, Foot and Ankle Ability Measures (FAAM), patient satisfaction, radiographic correction, and complications.
Median VAS of pain decreased from 8 before surgery to 1 after surgery (P < .001). Median FAAM score increased from 41.7 to 95.2 after surgery (P < .001). Radiographic comparison demonstrated correction of preoperative varus malalignment in all but 1 patient. No patients developed subsequent subtalar arthritis or pain. Three patients had mild persistent instability, all of which was managed nonoperatively. One of the patients with persistent instability also developed chronic regional pain syndrome following surgery. At final follow-up, 25 of 28 patients rated their satisfaction as good or excellent and 3 as fair. No patients required revision surgery.
Lateral ligament reconstruction utilizing a near-anatomically placed and tensioned allograft tendon was a viable option in treating recurrent and complex lateral instability. Not sacrificing the peroneal tendons avoided loss of eversion strength. Near-anatomic placement of the allograft provided good ankle stability without sacrificing subtalar motion or predisposition to subtalar arthritis in short-term follow-up.
Treatment of patients with Charcot midfoot destruction is a difficult and increasingly common clinical problem. The pathoanatomical features of Charcot neuropathy have been evaluated in only a few studies. This study evaluated whether medial navicular subluxation (adduction of the navicular on the talus) is a radiographic finding present in patients with Charcot neuroarthropathy.
A retrospective review of 143 consecutive patients diagnosed with Charcot arthropathy of the foot from January 2004 to May 2011 was performed. Patients were identified based on a clinical diagnosis code 713.5 during an outpatient clinic visit with 2 surgeons at a single institution. After exclusion criteria were applied, a series of radiographs of 50 feet in 40 patients were compared with radiographs from an age-matched control group. Radiographic data including talonavicular coverage angle and talonavicular uncoverage percentage were collected.
The mean talonavicular coverage angle of the Charcot arthropathy group was 1.5 degrees and of the control group 12.1 degrees (P < .05). The talonavicular uncoverage value for the Charcot arthropathy group was 12.2% and for the control group 22.0% (P < .001).
Medial navicular subluxation was a radiographic finding that was more commonly present in patients with Charcot arthropathy than in a matched control group. It is theorized that this finding is attributable to an unopposed pull of the posterior tibial tendon on the destabilized navicular.
Our aim was to assess whether the Lauge-Hansen (LH) and the Muller AO classification systems for ankle fractures radiographically correlate with in vivo injuries based on observed mechanism of injury.
Videos of potential study candidates were reviewed on YouTube.com. Individuals were recruited for participation if the video could be classified by injury mechanism with a high likelihood of sustaining an ankle fracture. Corresponding injury radiographs were obtained. Injury mechanism was classified using the LH system as supination/external rotation (SER), supination/adduction (SAD), pronation/external rotation (PER), or pronation/abduction (PAB). Corresponding radiographs were classified by the LH system and the AO system.
Thirty injury videos with their corresponding radiographs were collected. Of the video clips reviewed, 16 had SAD mechanisms and 14 had PER mechanisms. There were 26 ankle fractures, 3 nonfractures, and 1 subtalar dislocation. Twelve fractures with SAD mechanisms had corresponding SAD fracture patterns. Five PER mechanisms had PER fracture patterns. Eight PER mechanisms had SER fracture patterns and 1 had SAD fracture pattern. When the AO classification was used, all 12 SAD type injuries had a 44A type fracture, whereas the 14 PER injuries resulted in nine 44B fractures, two 44C fractures, and three 43A fractures.
When injury video clips of ankle fractures were matched to their corresponding radiographs, the LH system was 65% (17/26) consistent in predicting fracture patterns from the deforming injury mechanism. When the AO classification system was used, consistency was 81% (21/26). The AO classification, despite its development as a purely radiographic system, correlated with in vivo injuries, as based on observed mechanism of injury, more closely than did the LH system.
Level IV, case series.
Ankle sprains are the most common injury among physically active people, with common sequelae including repeated episodes of giving way, termed functional ankle instability. Copers are a cohort in ankle research comprised of those who have sprained their ankle but have not suffered any further dysfunction. The use of an elastic tape, Kinesio Tape, in sports medicine practice has recently gained popularity and may help improve postural control deficits related to functional ankle instability. The purpose of this study was to examine the immediate and prolonged effects of Kinesio Taping on postural control in healthy, coper, and unstable ankles as measured through single-limb balance on a force plate.
Sixty physically active, college-aged participants (72.5 ± 9.7 cm, 74.2 ± 16.2 kg, 21.5 ± 2.6 years) were stratified into healthy, coper, or unstable groups using the Cumberland Ankle Instability Tool (CAIT) combined with their history of ankle injury. Dependent variables included time-to-boundary (TTB) measures and traditional center of pressure (COP) measures in both the mediolateral (frontal) and anteroposterior (sagittal) planes. Testing was performed prior to tape application, immediately after application of the tape, 24 hours following tape application, and immediately after tape removal.
Significant differences between groups were observed for COP standard deviation and range in the sagittal plane. Significant differences between tape conditions for TTB absolute minima and standard deviation were also noted. Post hoc testing revealed large to medium effect sizes for the group differences and very small effect sizes for the differences between conditions.
Our study did not reveal decisively relevant changes following application of Kinesio Tape to the ankle. However, we did observe sagittal plane postural control deficits in subjects with ankle instability measured through summary COP variables over 20-second trials.
Ankle instability is a concern for many clinicians. Kinesio Taping, although a popular form of clinical intervention, remains understudied. Evidence from this study does not support the use of Kinesio Taping for improving postural control deficits in those with ankle instability.
The objective of this study was to determine whether there is a difference in fracture pattern and severity of comminution between tibial plafond fractures with and without associated fibular fractures using computed tomography (CT). We hypothesized that the presence of an intact fibula was predictive of increased tibial plafond fracture severity.
This was a case control, radiographic review performed at a single level I university trauma center. Between November 2007 and July 2011, 104 patients with 107 operatively treated tibial pilon fractures and preoperative CT scans were identified: 70 patients with 71 tibial plafond fractures had associated fibular fractures, and 34 patients with 36 tibial plafond fractures had intact fibulas. Four criteria were compared between the 2 groups: AO/OTA classification of distal tibia fractures, Topliss coronal and sagittal fracture pattern classification, plafond region of greatest comminution, and degree of proximal extension of fracture line.
The intact fibula group had greater percentages of AO/OTA classification B2 type (5.5 vs 0, P = .046) and B3 type (52.8 vs 28.2, P = .013). Conversely, the percentage of AO/OTA classification C3 type was greater in the fractured fibula group (53.5 vs 30.6, P = .025). Evaluation using the Topliss sagittal and coronal classifications revealed no difference between the 2 groups (P = .226). Central and lateral regions of the plafond were the most common areas of comminution in fractured fibula pilons (32% and 31%, respectively). The lateral region of the plafond was the most common area of comminution in intact fibula pilon fractures (42%). There was no statistically significant difference (P = .71) in degree of proximal extension of fracture line between the 2 groups.
Tibial plafond fractures with intact fibulas were more commonly associated with AO/OTA classification B-type patterns, whereas those with fractured fibulas were more commonly associated with C-type patterns. An intact fibula may be predictive of less comminution of the plafond. The lateral and central regions of the plafond were the most common areas of comminution in tibial plafond fractures, regardless of fibular status.
Level III, case control study.
Most patients with Achilles tendinopathy (AT) are treated successfully with physiotherapy involving eccentric calf training. In some patients, gastrocnemius contracture persists and there are reports of improvement following gastrocnemius release. We present the first series of patients to have proximal medial gastrocnemius release (PMGR) for AT.
16 PMGRs (12 patients) were performed at our institution over a 2-year period. Nine patients (10 PMGRs) were available for follow-up. The mean age of patients was 45 years (range, 25-63 years), with 5 female and 4 male subjects. The average follow-up period was 2.5 years (range, 1.7-3.3 years). The sample was divided into noninsertional and insertional tendinopathy, with 5 PMGRs per group. Outcome measures were visual analog scale (VAS) scores, Victorian Institute of Sport Assessment–Achilles (VISA-A) scores, American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, and overall satisfaction. Complications and further procedures were also recorded.
At an average of 2.5 years of follow-up, 6 out of 9 patients were highly satisfied. The noninsertional tendinopathy group enjoyed better results than the insertional group: mean VISA-A scores improved by 59% (noninsertional) versus 22% (insertional); mean AOFAS scores improved by 29% (noninsertional) versus 15% (insertional). The improvement in the noninsertional group was statistically significant (P < .05) for all 3 outcome measures.
PMGR was an outpatient procedure that was well tolerated without wound healing concerns due to the proximally based incision. Patients with noninsertional tendinopathy who have failed conservative treatment can expect notable improvement, with VISA-A scores possibly normalizing after the procedure. We recommend PMGR for patients suffering recalcitrant noninsertional AT in whom gastrocnemius contracture persists despite an eccentric stretching program.
Level IV, case series.
Prior studies reported improved gait after total ankle arthroplasty and better parameters of gait than those reported in earlier studies of patients after ankle arthrodesis. However, there are very limited data prospectively evaluating the effects on gait after ankle arthroplasty compared with ankle arthrodesis. Controversy remains regarding the relative advantages and disadvantages of these 2 treatments and especially the differences in function between them.
We performed a prospective study involving 28 patients with posttraumatic and primary ankle osteoarthritis and a control group of 14 normal volunteers. We compared gait in 14 patients who had undergone ankle arthrodesis with the gait of 14 patients who had ankle arthroplasty preoperatively and at 1 year postoperatively. Three-dimensional gait analysis was performed with a 12-camera digital-motion capture system. Temporospatial measurements included stride length and cadence. The kinematic parameters that were measured included the sagittal plane range of motion of the ankle and the coronal plane range of motion of the ankle. Double force plates were used to collect kinetic parameters such as ankle coronal and plantar flexion–dorsiflexion moments and sagittal plane ankle power. Center of pressure (CoP) and its progression in gait cycle were calculated.
Baseline parameters showed comparability among the treatment and control groups. Temporospatial analysis, using time as the main effect, showed that compared with ankle arthrodesis, patients with total ankle arthroplasty had higher walking velocity attributable to both increases in stride length and cadence as well as more normalized first and second rockers of the gait cycle. Kinematic analysis, using time and intervention as the main effects, showed that patients who had ankle arthroplasty had better sagittal dorsiflexion (P = .001), whereas those undergoing ankle arthrodesis had better coronal plane eversion (P = .01). Neither ankle arthrodesis nor arthroplasty altered the CoP progression during stance phase. Total ankle arthroplasty produced a more symmetrical vertical ground reaction force curve, which was closer to that of the controls than was the curve of the ankle arthrodesis group.
Patients in both the arthrodesis and arthroplasty groups had significant improvements in various parameters of gait when compared with their own preoperative function. Neither group functioned as well as the normal control subjects. Neither group was superior in every parameter of gait at 1 year postoperatively. However, the data suggest that the major parameters of gait after ankle arthrodesis in deformed ankle arthritis are comparable to gait function after total ankle arthroplasty in nondeformed ankle arthritis.
Level II, prospective comparative study.
Chronic exertional compartment syndrome (CECS) is a condition that causes reversible ischemia and lower extremity pain during exercise. To date there are few large studies examining the characteristics of patients with CECS. This study aimed to present these characteristics by examining the largest published series of patients with a confirmed diagnosis of the disorder.
An IRB-approved, retrospective review was undertaken of patients with a suspected diagnosis of CECS undergoing pre- and postexercise compartment pressure testing between 2000 and 2012. Patients were evaluated for gender, age, duration of symptoms, pain level, specific compartments involved, compartment pressure measurements, and participation and type of athletics.
Two-hundred twenty-six patients (393 legs) underwent compartment pressure testing. A diagnosis of CECS was made in 153 (67.7%) patients and 250 (63.6%) legs with elevated compartment measurements; average age of the patients was 24 years (range, 13-69 years). Female patients accounted for 92 (60.1%) of those with elevated pressures. Anterior and lateral compartment pressures were elevated most frequently, with 200 (42.5%) and 167 (35.5%) compartments, respectively. One hundred forty-one (92.2%) patients reported participation in sports, with running being the most common individual sport and soccer being the most common team sport. Duration of pain prior to diagnosis averaged 28 months.
Although there is ample literature pertaining to the diagnostic criteria and treatment algorithm of the condition, few papers have described the type of patient most likely to develop CECS. This is the largest study to date to evaluate the type of patient likely to present with chronic exertional compartment syndrome.
Level III, retrospective review.
There are few long-term studies evaluating tarsal coalition resections. The purpose of this study was to compare patient outcomes following resection of calcaneonavicular (CN) and talocalcaneal (TC) bars and to determine the relationship between the extent of a coalition and the outcome of resection.
Patients younger than 18 years receiving resection for symptomatic tarsal coalition (1991-2004 inclusive) were eligible to participate. Follow-up evaluation included clinical examination to assess range of motion and self-reported functional outcome questionnaires. Two validated functional scales were used: the American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Module, and the Foot Function Index (FFI). Twenty-four patients with 32 tarsal coalition resections (19 CN and 13 TC feet) were included in this study. For CN and TC patients, the mean age at the time of surgery was 11.8 ± 1.1 and 11.9 ± 2.5 years, and the mean age at follow-up was 27.1 ± 1.1 and 25.0 ± 2.5 years, respectively.
Inversion and eversion were significantly less for TC feet when compared with CN (P = .03 and P = .01, respectively). No difference was noted between the CN and TC groups with respect to outcome scores. Furthermore, no association was noted between the size of TC coalition or hindfoot valgus angle with respect to outcome scores.
Resected CN and TC bars behaved similarly in the long term in terms of function and patient satisfaction. Favorable results were attained when resections were performed on TC coalitions that were greater than 50% of the posterior facet and hindfoot valgus angles greater than 16 degrees.
Level III, retrospective comparative study.
Computed tomography (CT)-based indices may be superior to plain radiographs in determining the adequacy of reduction following operative fixation of the syndesmosis in unstable ankle fractures. This study assessed the reliability and accuracy of four CT-based methods for measurement of rotational malreduction of the fibula.
A simulated Weber C ankle fracture was created by performing an osteotomy in 9 cadaver ankles. The fibula was rotated and fixed in neutral (0 degrees) and 10 to 30 degrees of internal and external rotation. Fifty-two CT images at the level of the syndesmosis were obtained in neutral and rotated positions and presented in random order to 3 independent observers. Measurements were made using commercial imaging software and 4 methods for interpreting CT scans. Interobserver reliability and accuracy were assessed and compared.
Methods 1 and 4 showed high anatomic variability. Methods 1, 2, and 4 had a test-retest repeatability of about 15 degrees. Method 1 varied erratically with direction and degree of malrotation (R2 = 0.15) and did not permit specification of a neutral range. Method 2 varied consistently and systematically with direction and degree of malrotation (R2 = 0.88). Receiver operating characteristic curve analysis indicated that method 2 identified malrotation better than did the other methods. Methods 3 and 4 were somewhat more difficult to perform.
Method 2, the angle between the tangent of the anterior tibial surface and the bisection of the vertical midline of the fibula at the level of the incisura, was fairly reliable and accurate and had greater ease of measurement compared with the other methods that were tested.
This study demonstrated that assessment of malrotation of fibular fractures by CT scan can be difficult. We believe that of the 4 methods tested in this study, method 2, the angle between the tangent of the anterior tibial surface and the bisection of the vertical midline of the fibula at the level of the incisura, was the most useful.
No single radiographic measurement takes into account complete foot alignment. We have created the Tripod Index (TI) to allow assessment of complex foot deformities using a standing anteroposterior (AP) radiograph of the foot. We hypothesized that TI would demonstrate good intraobserver and interobserver reliability and correlate with currently accepted radiographic parameters, in both flatfoot and cavovarus foot deformities.
Three groups of patients were studied: 26 patients (30 feet) with flatfoot, 29 patients (30 feet) with cavovarus foot, and 51 patients (60 feet) without foot deformity as controls. Weight-bearing radiographs were obtained: foot AP with a hemispherical marker around the heel plus standard lateral and hindfoot alignment views. Radiographic measurements were made by 2 blinded investigators. Statistical analysis included intraclass correlation coefficients (ICCs), correlation of the TI with existing radiographic measurements using Pearson coefficients, and comparison between patient groups using analysis of variance.
Intraobserver and interobserver ICCs of TI (0.99 and 0.98, respectively) were excellent. In the flatfoot group, TI significantly correlated with AP talonavicular coverage angle (r = 0.43), medial cuneiform–fifth metatarsal height (r = -0.59), coronal plane hindfoot alignment (r = 0.53), and clinical hindfoot alignment (r = 0.39). In the cavovarus foot group, TI correlated significantly with AP talonavicular coverage angle (r = 0.77), calcaneal pitch angle (r = 0.39), medial cuneiform–fifth metatarsal height (r = -0.65), coronal plane hindfoot alignment (r = 0.55), and clinical hindfoot alignment (r = 0.61). Statistically significant differences between flatfoot-control and cavovarus foot–control were found in TI, AP talonavicular coverage angle, lateral talo–first metatarsal angle, calcaneal pitch angle, medial cuneiform–fifth metatarsal height, coronal plane hindfoot alignment, and clinical assessment of hindfoot alignment (all with P < .001).
The TI was demonstrated to be a valid and reliable radiographic measurement to quantify the magnitude of complex foot deformities when evaluating flatfoot and cavovarus foot.
The TI may be helpful as an integrated assessment of complex foot deformities. Further clinical studies are recommended.
Level III, retrospective comparative study.
Tibiotalocalcaneal arthrodesis in patients with large segmental bony defects presents a substantial challenge to successful reconstruction. These defects typically occur following failed total ankle replacement, avascular necrosis of the talus, trauma, osteomyelitis, Charcot, or failed reconstructive surgery. This study examined the outcomes of tibiotalocalcaneal (TTC) arthrodesis using bulk femoral head allograft to fill this defect.
Thirty-two patients underwent TTC arthrodesis with bulk femoral head allograft. Patients who demonstrated radiographic union were contacted for SF-12 clinical scoring and repeat radiographs. Patients with asymptomatic nonunions were also contacted for SF-12 scoring alone. Preoperative, intraoperative, and postoperative factors were analyzed to determine positive predictors for successful fusion.
Sixteen patients healed their fusion (50% fusion rate). Diabetes mellitus was found to be the only predictive factor of outcome; all 9 patients with diabetes developed a nonunion. In this series, 19% of the patients went on to require a below-knee amputation.
Although the radiographic fusion rate was low, when the 7 patients who had an asymptomatic nonunion were combined with the radiographic union group, the overall rate of functional limb salvage rose to 71%. TTC arthrodesis using femoral head allograft should be considered a salvage procedure that is technically difficult and carries a high risk for complications. Patients with diabetes mellitus are at an especially high risk for nonunion.
Therapeutic level IV.
Many procedures have been described for correction of bunionette deformity. For symptomatic type I deformity, the authors have routinely performed a subcapital oblique osteotomy of the fifth metatarsal. The purpose of this study was to report the medium-term results of this procedure.
This is a retrospective review of patients who underwent subcapital oblique osteotomy for correction of type I bunionette deformity. Patients were evaluated radiographically and clinically. Sixteen feet in 14 patients were available at final follow-up.
At a mean 2.9-year follow-up, 88% of patients had good or excellent clinical result, 88% of patients had no limitation in activity, and mean pain score on a visual analog scale was 1.6 out of 10. Radiographically, a statistical difference was found when we compared the preoperative and 6-week follow-up fifth metatarsophalangeal angle; however, no statistical difference was found in the fourth to fifth intermetatarsal angle at any time or in comparison of the preoperative and final follow-up fifth metatarsophalangeal angles.
We found the subcapital oblique osteotomy of the fifth metatarsal to provide reliable clinical results for correction of painful type I bunionette deformity.
Level IV, retrospective case series.
Residual forefoot supination is commonly encountered during a flatfoot reconstruction, and a new technique for its treatment is described. Contrary to the standard Cotton osteotomy, a plantar closing wedge osteotomy of the medial cuneiform (PCWOMC) was performed, which has a number of advantages.
We followed 10 feet in 9 patients who had a PCWOMC performed as the last step of a standard flatfoot reconstruction for the correction of residual forefoot supination. These patients were evaluated pre- and postoperatively by standardized radiographic parameters, Short Form-12 (SF-12), and Foot and Ankle Outcome Score (FAOS).
Patients were followed for an average of 25.8 months with final radiographic analysis performed at an average of 9.9 months. A significant difference (P < .001) between pre- and postoperative parameters was demonstrated for both lateral talus–first metatarsal angle and medial-cuneiform-to-ground distance. Likewise, there was a statistically significant improvement in the SF-12 score and 4 out of 5 components of the FAOS. One patient developed internal hardware–related symptoms, which were relieved following implant removal. All osteotomies healed uneventfully.
A PCWOMC can be considered an alternative to the Cotton osteotomy for the treatment of forefoot supination deformity in adult flatfoot reconstruction. The main advantage of this technique over the Cotton osteotomy was simplicity, as an additional dorsal incision and bone graft were not required.
Level IV, retrospective case series.
Ball and socket ankle (BASA) deformity is a rare condition. Little is known about outcomes and treatments in the adult population.
Retrospective comparative review was performed of 13 patients treated for BASA with a minimum follow-up of 2.5 years. Evaluation included clinical and radiographic review, outcome scores, a questionnaire, and a subjective satisfaction survey.
Nine patients with correctable valgus deformity not associated with arthritis of the ankle joint underwent a supramalleolar osteotomy (SMO). Four patients underwent arthrodesis—2 a tibiotalocalcaneal (TTC) arthrodesis and 2 a pantalar arthrodesis. AOFAS scores improved from 30.1 to 77.6 (range, 16-82) (P < .05) in the SMO group. AOFAS scores improved from 24 to 60.5 (range, 16-66) (P < .05) in the arthrodesis group. Arthritis grade in the SMO patients was unchanged in 4 patients at final follow-up and worsened in 5 patients by only 1 grade. Nine patients reported good results (all 4 arthrodesis patients, 5 SMO patients) and 4 reported fair results (all SMO patients).
BASA deformity and dysfunction can be improved with corrective surgery.
Level III, prospective comparative study.
The purpose of this study was to evaluate the clinical outcomes and usefulness of OK-432 (Picibanil) sclerotherapy as a new option in the conservative treatment of patients with malleolar bursitis of the ankle.
Retrospectively, we reviewed a total of 20 consecutive patients (20 feet) in whom OK-432 sclerotherapy had been performed between March 2009 and June 2010. After aspiration of fluid in the malleolar bursal sac, 0.05 mg of OK-432 was injected into the malleolar bursal sac. We evaluated the clinical outcomes and side effects at the following time points: 2 weeks, 1 month, 3 months, 6 months, and 1 year after OK-432 sclerotherapy. The responses to the treatment were assessed according to the degree of fluctuation, shrinkage of the bursal sac, and soft tissue swelling.
Complete resolution was observed in 19 patients (95%) after the first or second application of OK-432 sclerotherapy, and a partial response was observed in 1 patient (5%) after a second application of OK-432 sclerotherapy. The physical component scores of SF-36 improved from 70.0 ± 6.8 to 76.5 ± 7.3 at the last follow-up (P = .0002).
OK-432 sclerotherapy was a useful procedure for patients not responding to the usual conservative treatment of malleolar bursitis of the ankle.
Level IV, retrospective case series.
This study was performed to investigate anterior ankle impingement after tendo-Achilles lengthening for long-standing equinus deformity in patients with residual poliomyelitis and to investigate whether the severity of preoperative equinus deformity affected the occurrence of symptomatic anterior impingement.
Twenty-seven consecutive patients (mean age, 43.8 ± 9.4 years) with residual poliomyelitis who underwent tendo-Achilles lengthening for equinus foot deformity were included. On lateral foot-ankle weight-bearing radiographs, the tibiocalcaneal angle, plantigrade angle, and McDermott grade were measured and the presence of anterior blocking spur was evaluated.
Eleven patients (40.7%) had anterior ankle impingement on radiographic findings preoperatively and 24 patients (88.9%) at latest follow-up. There was a significant difference in McDermott grade between preoperative and latest follow-up (P < .001). There were significant differences in tibiocalcaneal angle and plantigrade angle between the patients with anterior ankle pain and without anterior ankle pain (P = .006 and .011, respectively) and between the patients with anterior blocking spur and without anterior blocking spur (P = .005 and .010, respectively).
Most patients with residual poliomyelitis had anterior ankle impingement after tendo-Achilles lengthening for long-standing equinus deformity, and the presence of symptomatic anterior ankle impingement was significantly associated with the severity of the equinus deformity. Therefore, for residual poliomyelitis patients with severe long-standing equinus deformity, surgeons should consider the possibility of a subsequent anterior procedure for anterior impingement after tendo-Achilles lengthening.
Level IV, retrospective case series.
Irreparable peroneal tendon tears are uncommon and require complex surgical decision making. Intercalary segment allograft reconstruction has been previously described as a treatment option; however, there are no reports of the outcomes of this technique in the literature. We describe our technique and present our results using this method.
A retrospective chart review was conducted to identify all patients who underwent intercalary allograft reconstruction of the peroneal tendons. Mechanism of injury, concomitant operative procedures, pertinent radiographic findings, pre- and postoperative physical examination, intercalary graft length, medical history, visual analog scale (VAS) score for pain, Short Form-12 (SF-12) physical health survey, Lower Extremity Functional Score (LEFS), and complications were reviewed.
Fourteen patients with peroneal tendon ruptures requiring reconstruction were identified. Mean follow-up was 17 months (range, 7-47 months; median, 12 months). The average length of the intercalary segment reconstructed was 10.8 ± 3.8 cm (range, 6-20 cm). The average postoperative VAS score decreased to 1.0 ± 1.4 (P = .0005). No patient had a higher postoperative pain score than preoperative pain score. Average postoperative eversion strength as categorized by the Medical Research Council grading scale improved to 4.8 ± 0.5 (P = .001). The average SF-12 score improved to 48.8 ± 7.8 (P = .02). The average LEFS improved to 86.4. ± 14.9 (P = .00001). Four patients experienced sensory numbness in the sural nerve distribution, and 2 of these were transient. There were no postoperative wound healing complications, infections, tendon reruptures, or reoperations. No allograft associated complications were encountered. All patients returned to their preinjury activity levels.
Allograft reconstruction of the peroneal tendons can improve strength, decrease pain, and yield satisfactory patient-reported outcomes. It can be performed without incurring the deleterious effects associated with tendon transfer procedures. We believe that allograft reconstruction is a safe and useful alternative in the treatment of irreparable peroneal tendon ruptures.
Level IV, retrospective case series.
Tibiotalocalcaneal arthrodesis is a salvage option for severe ankle and hindfoot deformities, arthritis of the ankle and subtalar joints, avascular necrosis of the talus, failed total ankle arthroplasty, and Charcot arthropathy. This multicenter study reports clinical experience with the hindfoot arthrodesis nail (HAN) in the treatment of patients with severe ankle and foot abnormalities.
Seven participating clinics from Europe and North America recruited 38 patients who underwent ankle/subtalar arthrodesis using retrograde nailing with the HAN. Information was collected regarding technical details, complications, and functional and quality of life outcomes (Short Form-36 [SF-36], American Academy of Orthopaedic Surgeons—Foot and Ankle Outcomes [AAOS-FAO], and numeric rating scale [NRS] for pain) after an average of 2 years of follow-up.
The rate of superficial wound infection was 2.4%. No deep soft tissue or bone infections were reported. The overall union rate was 84%. At the time of follow-up, low pain levels were reported, with a mean NRS of 2.2; the mean AAOS-FAO score was 38; and the SF-36 mean physical and mental health component scores were 41.2 and 52.5, respectively. All 13 patients who were unable to work prior to surgery were able to fully return to work.
The HAN offered a safe and reliable salvage option for tibiotalocalcaneal arthrodesis in patients with severe ankle and hindfoot disease. It achieved acceptable functional outcome and low complication rates despite the challenging patient cohort. A considerable socioeconomic benefit appeared to result based on the high proportion of patients who were able to return to work postoperatively.
Level IV, retrospective case series.
Flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendon transfers are frequently used to restore the function of a deficient tibialis posterior tendon in stage II adult acquired flatfoot deformity (AAFD). Either transfer causes some loss in toe flexion force, although the decision to tenodese the cut tendon to restore associated function remains controversial. This study quantified changes in plantar force before and after tendon transfer and with or without distal tenodesis in a cadaveric model.
The plantar force distribution of 10 matched pairs of statically loaded cadaveric lower extremities was investigated. Each foot was tested when it was intact, after FDL/FHL tendon transfer, and after tendon transfer + tenodesis.
Transfer of either FHL or FDL showed a statistically significant decrease in flexion force of the great toe (P < .01) and lesser toes (P < .001), respectively. Subsequent tenodesis in either tendon demonstrated an ability to restore flexion force in the great (P < .05) and lesser (P < .01) toes, respectively, with the FHL transfer + tenodesis restoring great toe loading to near pretransfer levels. Following either transfer, plantar force increased in the medial forefoot; this was sustained with FDL transfer + tenodesis but reduced under FHL transfer + tenodesis. Lateral forefoot force increased modestly (8%) with FHL transfer (P < .05) but returned to near intact levels with tenodesis. FDL transfer + tenodesis resulted in increased medial midfoot and heel loading.
FHL or FDL transfer notably reduces associated toe flexion force. This loss can be restored to near normal levels with tenodesis for FHL transfer. As increased lateral forefoot loading is commonly associated with AAFD corrective procedures, FHL tenodesis may mitigate the unintended increases caused by the tendon transfer. The medial midfoot and heel loading with FDL transfer + tenodesis underscores that tendon transfers alone do not reestablish the passive architecture of the foot but augment deficient subtalar inversion force.
This cadaveric study shows that the FHL is more biomechanically suitable for tibialis posterior tendon insufficiency than the FDL, which may be a basis for a study to investigate whether it is superior in a clinical situation.
Arthrodesis is currently the most commonly performed surgical procedure for the treatment of arthritis of the first metatarsophalangeal (MTP) joint. Hemiarthroplasty of the first MTP joint has been shown to have inferior clinical results and higher revision rates. The objective of this study was to assess the clinical outcome of the salvage of failed hallux phalangeal hemiarthroplasty with conversion to arthrodesis.
A retrospective review of patients who underwent salvage of the first MTP joint hemiarthroplasty with conversion to arthrodesis was performed. Preoperative assessment included the visual analog pain (VAP) scale and AOFAS Hallux Metatarsophalangeal Interphalangeal scoring system (AOFAS-HMI). Postoperative outcomes were graded via AOFAS-HMI, VAP, and Foot and Ankle Ability Measure (FAAM).
Twenty-one hemiarthroplasties were converted to arthrodesis in 21 patients, with 18 available for follow-up included in the study. There were 13 women and 5 men. Local autologous bone graft was used in 12 cases, while 6 patients required tricortical iliac crest bone graft for the treatment of extensive bone loss. At final follow-up, at a mean of 4.3 years, the average VAS pain score had diminished to 0.75 from 7.8 preoperatively out of 10, while the mean AOFAS-HMI improved from 36.2 out of 100 preoperatively to 85.3 out of 90 (modified to exclude first MTP motion). The mean FAAM ADL/sports were 97.3/91.3, respectively. All patients achieved fusion although at a longer interval than primary fusions.
Conversion from a failed hallux phalangeal hemiarthroplasty to arthrodesis showed similar success to primary arthrodesis which was achieved in the majority of cases with the use of regional bone graft for small defects. However, the time to fusion was longer than that of primary arthrodesis, and it sometimes required structural bone graft for augmentation.
Level IV, retrospective case series.
Successful screw fixation of reduced posterior facet fragments to the unexposed, nondisplaced sustentaculum tali avoids breaching the subtalar joint or disrupting surrounding soft tissue structures. Safe passage for screw fixation through this narrow bony corridor has not been rigorously defined.
Computed tomography scans of 8 cadaveric feet were digitally reconstructed in 3-D; 3.5-mm-diameter screws were simulated, aiming at the center of the sustentaculum tali from 5 locations (0%, 25%, 50%, 75%, and 100%) along the posterolateral facet joint. The range of entry points, screw paths trajectories, and screw lengths that did not breach the subtalar joint or the medial calcaneal cortex were evaluated.
To prevent violation of the subtalar joint or the medial calcaneal cortex while reaching the center of the sustentaculum tali, screws must be inserted at least 5 mm below the joint line. Screw placement 15 ± 1 mm below the posterior facet measured perpendicular to the joint line provided the widest safe corridor with the trajectory of the ranges from 6 to 36 degrees parallel to the joint depending on the location along the posterior facet and 20 ± 2 degrees perpendicular to the joint at all locations. The average maximal length of screws placed at the ideal entry points ranged from 44 to 46 mm, longest at the 100% location and shortest at the 25% location.
Operative guidelines facilitating instrumentation into the sustentaculum tali have been defined applying to most calcanei, assuming the fractures are well reduced: screws, approximately 40 mm in length, should be started 15 mm below the posterior facet measured perpendicular to the joint line and aimed 20 degrees perpendicular to the joint line toward the joint and 6 to 36 degrees anteversion parallel to the joint line increasing at each position from anterior to posterior.
The operative guidelines described in this study may assist surgeons in the placement of screws for the fixation of posterior facet fragments to the sustentaculum tali.
Ankle valgus is encountered in children with a variety of congenital musculoskeletal disorders, including multiple hereditary exostoses (MHE). Guided growth with temporary distal tibial medial hemiepiphysiodesis (DTMH) may correct the deformity; however, exostoses about the ankle commonly observed in MHE patients may hinder correction and increase the risk of recurrence. Thus, the purpose of this study was to review the outcomes of DTMH in treatment of ankle valgus in MHE versus other diagnosis (non-MHE).
Medical records and radiographs of patients undergoing DTMH for ankle valgus between January 1, 2005, and November 1, 2010, at a single pediatric orthopedic hospital were retrospectively analyzed. Radiographs obtained preoperatively and at 6-month intervals postoperatively were reviewed and the tibiotalar angle was measured.
Fifty-eight ankles in 41 patients met inclusion criteria, with minimum follow-up of 12 months (mean, 34 months). Mean age was 10 years (range, 4-14 years). MHE was the most common underlying diagnosis (19 ankles, 33%). The rate of tibiotalar angle correction (mean ± standard deviation) with hardware in place was 0.37 ± 0.28 deg/mo in MHE ankles and 0.51 ± 0.42 deg/mo in non-MHE ankles (P = .161). Following hardware removal, the rate of recurrence was faster in MHE (0.29 ± 0.25 deg/mo) compared with non-MHE ankles (0.12 ± 0.19 deg/mo) (P = .059), and more total recurrent valgus deformity was observed in MHE (7.8 ± 8.2 degrees) than non-MHE ankles (3.4 ± 4.6 degrees) (P = .08) over a similar follow-up period (mean 23.4 vs 23.6 months, respectively), with differences approaching statistical significance.
MHE is a common cause of ankle valgus in children. Guided growth interventions in this population can be successful but require special consideration given the potential for relatively gradual deformity correction and rapid recurrence following hardware removal in the skeletally immature.
Level III, retrospective comparative study.
Proximal interphalangeal (PIP) joint fusion is a commonly performed procedure for lesser-toe deformities. There are various techniques described to accomplish it. We report the results of PIP joint fusion carried out with an intramedullary fusion device in 150 consecutive toes. The aim of our study was to evaluate the outcomes of PIP joint fusion with this technique.
A total of 150 toes in 140 consecutive patients who underwent PIP joint fusions of the lesser toes with a StayFuse implant were included in our study. The mean age of the patients was 69.5 years, and the mean follow-up was 18 months. Clinical, radiologic, and subjective evaluations as well as preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores were carried out.
Of the PIP joints, 95.3% were clinically asymptomatic, but the radiologic fusion was 73%. The mean preoperative AOFAS score improved from 22.9 to 81.6 at follow-up. There were implant-related complications in 8 toes. Ninety-five percent of the patients were satisfied with the procedure, and 3.3% of the patients needed revision surgery.
This technique maintained PIP joint alignment and provided rotational and angular stability with high patient satisfaction and low complication and reoperation rates. We conclude that this is a reproducible technique and an alternative for PIP joint fusions.
Level IV, retrospective case series.
Numerous modalities are used today to treat symptomatic osteochondral lesions in the ankle. However, there are ongoing challenges with the treatment of certain lesions, and concerns exist regarding long-term effectiveness.
The purpose of the study was to collect clinical outcomes of pain and function in retrospectively and prospectively enrolled patients treated with particulated juvenile cartilage for symptomatic osteochondral lesions in the ankle. This study collected outcomes and incidence of reoperations in standard clinic patients. The analysis presented here includes final follow-up to date for 12 males and 11 females representing 24 ankles. Subjects had an average age at surgery of 35.0 years and an average body mass index of 28 ± 5.8. Fourteen ankles had failed at least 1 prior bone marrow stimulation procedure. The average lesion size was 125 ± 75 mm2, and the average depth was 7 ± 5 mm. In conjunction with the treatment, 9 (38%) ankles had 1 concomitant procedure and 9 (38%) had more than 1 concomitant procedure. Clinical evaluations were performed with an average follow-up of 16.2 months.
Average outcome scores at final follow-up were American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale 85 ± 18 with 18 (78%) ankles demonstrating good to excellent scores, Short-Form 12 Health Survey (SF12) physical composite score 46 ± 10, SF12 mental health composite score 55 ± 7.1, Foot and Ankle Ability Measure (FAAM) activities of daily living 82 ± 14, FAAM Sports 63 ± 27, and 100-mm visual analog scale for pain 24 ± 25. Outcomes data divided by lesion size demonstrated 92% (12/13) good to excellent results in lesions 10 mm or larger and those smaller than 15 mm. To date, 1 partial graft delamination has been reported at 16 months.
Preliminary data from a challenging clinical population with large, symptomatic osteochondral lesions in the ankle suggest that treatment with particulated juvenile cartilage could improve function and decrease pain. Longer follow-up and additional subjects are needed to evaluate improvement level and ideal patient indications.
Level IV, case series.
There are a great number of studies on the outcome of surgery for Morton’s neuroma. However, there is a lack of controlled trials to determine the outcome in general and for the 2 most used surgical approaches. This prospective and randomized trial studied the outcome and adverse events of resected primary Morton’s neuromas, comparing plantar and dorsal incisions.
Seventy-six patients were randomized to treatment with either a plantar or a dorsal incision by 2 senior surgeons. Questionnaires were evaluated and physical examinations performed at baseline and at 3 and 12 months postoperatively by the treating surgeon and at a mean of 34 months (range, 28-42 months) by an independent surgeon. The follow-up rate was 93%.
Histological examination of specimens verified resection of nerves in all cases except 1, which was in the dorsal group (artery). The main outcome variable, pain at daily activities, was significantly reduced by 96% (plantar) and 97% (dorsal) and restrictions in daily activities were reduced by 77% (plantar) and 67% (dorsal) at the final follow-up. Scar tenderness was noted by 3% (plantar) and 0% (dorsal) at the final evaluation. Clinically good results with surgery were noted in 87% (plantar) and 83% (dorsal) of cases. There were 5 complications in the plantar group and 6 in the dorsal group, with a difference in type of complications.
This study demonstrated 87% (plantar) and 83% (dorsal) clinically good outcomes and no significant differences between the procedures in regard to pain, restrictions in daily activities, and scar tenderness. However, there was a difference between the groups in the type of complications.
Level I, prospective randomized trial.
A fairly high prevalence of wound complications after open reduction and internal plate fixation (ORIF) of closed calcaneal fractures via the extensile lateral approach has been reported. The goal of this study was to analyze and identify independent risk factors for wound complications among closed calcaneal fractures undergoing ORIF.
The medical records of all closed calcaneal fracture patients who underwent ORIF from July 2005 to July 2012 were reviewed to identify those who developed a wound complication. Then we constructed a univariate and multivariate logistic regression to evaluate the independent associations of potential risk factors for surgical wound complication. Records showed 479 patients who underwent ORIF of a closed calcaneal fracture from July 2005 to July 2012. The patients were followed for 3 to 28 months, with an average follow-up period of 14.2 months. Eleven patients had bilateral fractures, for a total of 490 fractured calcanei.
The overall rate of postoperative wound complications following ORIF of closed calcaneus fractures was 17.8% (87 wound complications in 490 operations). With the regression model, smoking history (odds ratio, 5.79; 95% CI: 1.55 to 21.70; P = .009), diabetes mellitus (odds ratio, 6.23; 95% CI: 1.37 to 28.31; P = .018), Sanders type (odds ratio, 5.44; 95% CI: 2.02 to 14.64; P = .001), number of residents and/or fellows present during the case (odds ratio, 1.63; 95% CI: 1.06 to 2.52; P = .028), duration of surgery (odds ratio, 4.54; 95% CI: 1.46 to 14.12; P < .001), estimated blood loss (odds ratio, 1.02; 95% CI: 1.01 to 1.04%; P < .001), and 10 or more people present in the operating room during the entire case (odds ratio, 2.30; 95% CI: 1.79 to 2.94; P < .001) were risk factors for wound complication. Tourniquet use (odds ratio, 0.02; 95% CI: 0.00 to 0.08; P < .001), which was associated with a decreased risk for the development of a wound complication, was observed as a protective factor. Diabetes mellitus, Sanders type, and smoking were the strongest risk factors for postoperative wound complication after adjusting for all other variables.
Smoking, diabetes mellitus, Sanders type, number of residents and/or fellows present during the case, duration of surgery, estimated blood loss, and high number of persons present in the operating room during the entire case were related to an increased risk for postoperative wound complication of closed calcaneal fractures following ORIF. Tourniquet use was associated with a decreased risk for the development of a wound complication.
Level III, retrospective comparative series.