Showing papers in "Journal of Foot & Ankle Surgery in 2010"
TL;DR: This clinical practice guideline (CPG) is a revision of the original 2001 document developed by the American College of Foot and Ankle Surgeons (ACFAS) heel pain committee.
Abstract: Heel pain, whether plantar or posterior, is predominantly a mechanical pathology although an array of diverse pathologies including neurologic, arthritic, traumatic, neoplastic, infectious, or vascular etiologies must be considered. This clinical practice guideline (CPG) is a revision of the original 2001 document developed by the American College of Foot and Ankle Surgeons (ACFAS) heel pain committee.
355 citations
TL;DR: The results confirmed that Böhler's angle, the quality of the reduction, and subtalar joint motion were important prognostic factors related to outcome, regardless of treatment; whereas gender and Sanders type had less influence on the results at the 2-year follow-up evaluation.
Abstract: We compared the outcomes of displaced intra-articular calcaneal fractures in 33 patients aged 65 to 75 years, who were treated either operatively (n = 18) or nonsurgically (n = 15), between December 2001 and December 2005. The operative treatment group scored higher on the American Orthopaedic Foot & Ankle Society ankle-hindfoot score and had less pain as measured with the 10-cm visual analog scale than did the nonsurgically treated group, with the differences being statistically significant (P < or = .05), suggesting that results can be improved by operative treatment. Bohler's angle, the quality of operative reduction, subtalar joint motion, gender, and the Sanders type of fracture were also analyzed and compared between the treatment groups. The results confirmed that Bohler's angle, the quality of the reduction, and subtalar joint motion were important prognostic factors related to outcome, regardless of treatment; whereas gender and Sanders type had less influence on the results at the 2-year follow-up evaluation. The prevalence of complications observed in the surgically treated group was similar to that reported in prior publications, except for subtalar arthritis (38.9%), which may have been higher because of the age of our patients and the duration of follow-up.
95 citations
TL;DR: In this paper, the authors identify risk factors for flatfoot deformity, which itself can be a causative factor for other foot and ankle pathologies, and find statistically significant associations of flatfoot with age, male gender, BMI, white-collar occupation, veteran status, bunion, hammertoe, calluses, arthritis, and poor health.
Abstract: Many factors have been suggested to cause flatfoot deformity. The purpose of this study was to identify risk factors for flatfoot deformity, which itself can be a causative factor for other foot and ankle pathologies. The National Health Interview Survey (Podiatry Supplement) from 1990 was analyzed to determine associations of various demographic factors and other foot and ankle pathologies with self-reported flatfoot deformity. We found statistically significant (P
92 citations
TL;DR: DI SPECT/CT is a highly accurate modality that considerably improves detection and discrimination of STI and OM while providing precise anatomic localization in the diabetic foot and promises to beneficially impact diabetic patient care.
Abstract: Sequential Tc-99m hydroxymethylene-diphosphonate (HDP) 3-phase bone (BS) and In-111 leukocyte scanning (WBCS) have been frequently used to evaluate the diabetic foot, as nonosteomyelitis BS uptake is repeatedly observed and osteomyelitis (OM) in WBCS is often uncertain without BS correlation. Additionally, both modalities are limited in lesion localization because of low resolution and lack of anatomic details. We investigated a method that combined BS/WBCS, and if needed, WBCS/bone marrow scanning (BMS) using SPECT/CT to accurately diagnose/localize infection in a practical protocol. Blood flow/pool images were obtained followed by WBC reinjection and next day dual isotope (DI) BS/WBCS planar and SPECT/CT. BMS/WBCS SPECT/CT (step 2 DI) was obtained on the following day when images were suspicious for mid/hindfoot OM. Diagnosis accuracy and confidence were judged for the various imaging combinations. Diagnosis was classified as OM, soft tissue infection (STI), both OM/STI, and other/no bony pathology by microbiology/pathology or follow-up. Distinction between various diagnostic categories and overall OM diagnostic accuracy in 213 patients were higher for DI than WBCS or BS alone, and for DI SPECT/CT than DI planar or SPECT only. Diagnostic confidence/lesion site was significantly higher for DI SPECT/CT than other comparative imaging methods. In a group of 97 patients with confirmed microbiologic/pathologic diagnosis, similar results were attained. Step 2 DI SPECT/CT performed in 67 patients further improved diagnostic accuracy/confidence. DI SPECT/CT is a highly accurate modality that considerably improves detection and discrimination of STI and OM while providing precise anatomic localization in the diabetic foot. This combined imaging technique promises to beneficially impact diabetic patient care.
88 citations
TL;DR: It is revealed that arthrodesis achieves better functional outcomes than total joint replacement and the operative techniques and prostheses for joint replacements are however still in an early stage of development and advances still need to be achieved.
Abstract: As first metatarsophalangeal joint arthrodesis is generally considered to be a successful procedure for the treatment of hallux rigidus, many surgeons question the usefulness of total joint replacement. In an effort to elucidate the clinical evidence, we undertook a systematic review of the literature comparing the functional outcomes of arthrodesis and joint replacement in first metatarsophalangeal surgery. Using multiple search engines and medical subject headings, 10 articles were eligible for inclusion: 5 featured arthrodesis and 5 featured total joint replacement. The American Orthopaedic Foot and Ankle Society-Hallux metatarsophalangeal-interphalangeal score was used in all articles. The mean age at operation was 53 years for joint replacement patients and 55 for those undergoing joint arthrodesis. Most patients in all studies were female. There was a significant increase from pre- to postoperative scores in both procedures. The median postoperative score for joint replacement was 83/100 (range 74-95) and 82/100 (range 78-89) for arthrodesis. The median revision rate in joint replacements was 7% (range 0%-10%) and 0% (range 0%-12%) for arthrodesis. This systematic review reveals that arthrodesis achieves better functional outcomes than total joint replacement. The operative techniques and prostheses for joint replacements are however still in an early stage of development and advances still need to be achieved to produce a more successful and anatomical prosthesis that could be functionally superior to an arthrodesis.
80 citations
TL;DR: This study supports the conclusion of previous studies, which stated that a higher level of awareness is needed to prevent permanent disability in patients with Chopart joint injuries.
Abstract: Injuries involving the Chopart joint complex are relatively rare and frequently missed or misdiagnosed, often leading to a poor functional outcome. This study was performed to determine the outcome and morbidity in patients with Chopart joint injuries, and to increase awareness of this severe injury. Patients with a Chopart dislocation or fracture-dislocation, treated between January 2004 and January 2010, were identified using the appropriate diagnosis code and reviewing all radiographs of patients diagnosed with hindfoot or midfoot injuries treated at our institution. Data on patient characteristics, trauma mechanism, delay, and treatment were collected using patient files, operation reports, and by reviewing radiographs. Outcome was determined using the American Orthopaedic Foot & Ankle Society midfoot score and a visual analog scale satisfaction score, in patients with a minimum follow-up of 6 months. Nine patients (1.5 per year) were identified, including 6 women. The mean patient age was 41.6 ± 25.1 years. The trauma mechanism was sprain or sports injury in 5 (55.6%), motor vehicle accident in 3 (33.33%), and a fall from height in 1 (11.11%) case. Seven patients with an average follow-up of 31.3 ± 19.2 months reported a mean American Orthopaedic Foot & Ankle Society midfoot score of 72 (range, 32-100) points and a mean visual analog scale score of 7.1 (range, 5-10). Four (57.14%) patients still experienced pain or had limitations in daily activities at the time of the final follow-up. This study supports the conclusion of previous studies, which stated that a higher level of awareness is needed to prevent permanent disability.
71 citations
TL;DR: Though a majority of patients did not experience the remaining symptoms represented in the interview, all results are pertinent and deserve understanding to provide better insight and care for the pregnant woman.
Abstract: The anatomic and physiologic changes occurring with pregnancy result in a variety of symptoms affecting the lower extremity. The purpose of this investigation is to provide a comprehensive look at the lower extremity changes experienced during pregnancy and correlate symptoms with underlying etiology in a literature review. In this retrospective study, 100 postpartum women were interviewed regarding the lower extremity changes experienced in pregnancy. The interview included dermatologic, vascular, neurologic, and musculoskeletal portions. Results demonstrate more than 50% of women reported faster toenail growth, roughened toenail texture, increased dryness of the skin, swelling of the foot, ankle, and leg, unsteady gait, increased foot width, and hip pain. Though a majority of patients did not experience the remaining symptoms represented in the interview, all results are pertinent and deserve understanding to provide better insight and care for the pregnant woman. Therefore, a thorough literature review is presented to correlate the outcomes of the present study with previously published research.
70 citations
TL;DR: Outpatient arthroscopic ankle arthrodesis appears to be less expensive for third party payers, and surgeons are paid more, whereas hospitals and ambulatory surgical centers get paid a greater proportion of the charges that they bill.
Abstract: Compared with traditional open arthrodesis, arthroscopic ankle arthrodesis has been associated with similar rates of fusion, decreased time to union, decreased pain, shorter hospital stay, earlier mobilization, reliable clinical results, and fewer complications. The aim of this case-control study was to analyze cost differences between outpatient arthroscopic and inpatient open ankle arthrodesis. To this end, the authors analyzed 20 ankle arthrodesis procedures: 10 performed by one surgeon on an inpatient basis using an open approach, and 10 performed by another surgeon on an outpatient basis arthroscopically. Patient age, body mass index, tourniquet time, length of stay, complications, days to clinical union, and insurance type, as well as charges and reimbursements for the surgeons and the hospital or surgery center were abstracted from the records. Statistically significant differences were observed between the outpatient arthroscopic and inpatient open arthrodesis groups for total site charges ($3898 +/- 0.00 versus $32,683 +/- $12,762, respectively, P < .0001), reimbursement to the surgeon ($1567 +/- $320 versus $1107 +/- $278, respectively, P = .003), and reimbursement to the hospital or ambulatory surgery center ($1110 +/- $287 versus $8432 +/- $2626, respectively); the ratio of hospital/surgery center charges to hospital/surgery center reimbursements was 28.48% for the inpatient arthroscopic group and 25.80% for the inpatient open arthrodesis group. Outpatient arthroscopic ankle arthrodesis, compared with inpatient open ankle arthrodesis, appears to be less expensive for third party payers, and surgeons are paid more, whereas hospitals and ambulatory surgical centers get paid a greater proportion of the charges that they bill.
65 citations
TL;DR: Gradual Charcot foot correction with the Taylor spatial frame plus minimally invasive arthrodesis is an effective treatment and no amputations were necessary during an average follow-up of 22 months.
Abstract: The goals of Charcot deformity correction are to restore osseous alignment, regain pedal stability, and prevent ulceration. Traditional reconstructive surgical approaches involve large, open incisions to remove bone and the use of internal fixation to attempt to fuse dislocated joints. Such operations can result in shortening of the foot and/or incomplete deformity correction, fixation failure, incision healing problems, infection, and the longterm use of casts or braces. We recommend a minimally invasive surgical technique for the treatment of Charcot deformity, which we performed on 11 feet in 8 patients. Osseous realignment was achieved through gradual distraction of the joints with external fixation, after which minimally invasive arthrodesis was performed with rigid internal fixation. Feet were operated on at various stages of Charcot deformity: Eichenholtz stage I (1 foot), Eichenholtz stage II (6 feet), and Eichenholtz stage III (4 feet). When comparing the average change in preoperative and postoperative radiographic angles, the transverse plane talar-first metatarsal angle (P = .02), sagittal plane talar-first metatarsal angle (P = .008), and calcaneal pitch angle (P = .001) were all found to be statistically significant. Complications included 3 operative adjustments of external or internal fixation, 4 broken wires or half-pins, 2 broken rings, and 11 pin tract infections. Most notably, no deep infection, no screw failure, and no recurrent ulcerations occurred and no amputations were necessary during an average follow-up of 22 months. Gradual Charcot foot correction with the Taylor spatial frame plus minimally invasive arthrodesis is an effective treatment.
65 citations
TL;DR: The "step-forward Hubscher maneuver" is introduced as an effective means of evaluating the flexibility of a pes planovalgus foot by negating the effects of a gastrocnemius or gastrocNemius-soleus equinus.
Abstract: Pediatric pes planovalgus deformity may be classified as flexible or rigid. The rigid pes planovalgus is often a result of a tarsal coalition, which is typically characterized as a painful unilateral or bilateral deformity, frequently associated with peroneal spasm. However, many tarsal coalitions are asymptomatic and demonstrate no peroneal spasm or pes planovalgus deformity. Likewise, the severe pes planovalgus foot type can demonstrate some of the same clinical and radiographic features of a tarsal coalition, especially in the obese adolescent patient. Also, peroneal spasm may occur in the noncoalesced foot, making diagnosis and etiology more difficult to elucidate. The authors believe that many patients with a pes planovalgus deformity lie in this "gray zone": somewhere between the frank osseous coalition and the flexible pes planovalgus. The "step-forward Hubscher maneuver" is introduced as an effective means of evaluating the flexibility of a pes planovalgus foot by negating the effects of a gastrocnemius or gastrocnemius-soleus equinus. This article focuses on the clinical examination and findings of specific imaging studies to assist in an accurate diagnosis of these complicated patients. This will also help to reveal the various surgical options that are appropriate for the individual patient. Emphasis is placed on computerized tomography (CT) imaging and offers enhanced methods for ordering this test to specifically evaluate middle facet coalitions of the subtalar joint. The authors also introduce "lateral tarsal wedging," an image finding associated with severe deformities, the implications of this finding, as well as its impact on surgical planning.
62 citations
TL;DR: Lateral column lengthening by means of calcaneus osteotomy rather than distraction arthrodesis of the calcaneocuboid joint, for correction of stage II posterior tibial tendon dysfunction is recommended.
Abstract: In this study, clinical and radiological results after lateral column lengthening by calcaneocuboid distraction arthrodesis and calcaneus osteotomy were compared. Thirty-three patients (35 feet) treated with lateral column lengthening by distraction arthrodesis (14 patients, 16 feet; group I) or by calcaneus osteotomy (19 patients, 19 feet; group II) for adult-acquired flatfoot deformity caused by stage II posterior tibial tendon dysfunction were compared retrospectively. Mean follow-up was 42.4 months (range, 6-78 months) for group I and 15.8 months (range, 6-32 months) for group II (P < .001). The American Orthopaedic Foot & Ankle Society ankle-hindfoot score was determined, 4 variables were measured on preoperative and postoperative weight-bearing radiographs, and a number of independent and outcome variables, including patient satisfaction, were recorded. Group 2 had a significantly higher American Orthopaedic Foot & Ankle Society score compared with group I (mean, 85 vs. 72, respectively; P < .02) at time of last follow-up, and there were no dissatisfied patients in group I, whereas 2 patients in group II were dissatisfied with the result of the operation. All radiological results were significantly better at time of follow-up in both groups (except for talocalcaneal angle in group I), although no significant differences were noted in the amount of change in radiographic measurements between the groups. No significant correlation was found between follow-up time and radiographic improvement, indicating stable radiographic measurements over time. In group II, 13 mild calcaneocuboid subluxations were observed. In both groups, 1 nonunion and 1 wound complication occurred. Based on our experience with the patients described in this report, we recommend lateral column lengthening by means of calcaneus osteotomy rather than distraction arthrodesis of the calcaneocuboid joint, for correction of stage II posterior tibial tendon dysfunction.
TL;DR: Both simple as well as more complex techniques that the authors use in the prevention and management of complications arising from external fixator pin sites are described, and solutions to the difficult task of incorporating externalfixator wires into negative-pressure dressings are described.
Abstract: The use of external fixation devices to assist in the management of lower extremity trauma and reconstruction continues to rise. Despite the distinct advantages of external fixation, complications from external fixators continue to exist. The complicated external fixator-associated pin site may be a potential source of significant morbidity, especially in the at-risk patient, which may lead to soft tissue healing problems and infections, as well as osteomyelitis. This article describes both simple as well as more complex techniques that the authors use in the prevention and management of complications arising from external fixator pin sites, and solutions to the difficult task of incorporating external fixator wires into negative-pressure dressings.
TL;DR: Based on the experience with ankle arthroplasty and the surgical management of hindfoot and ankle trauma, the use of NWPT in the immediate postoperative period is both safe and efficacious.
Abstract: Negative-pressure wound therapy (NPWT) is commonly used for chronic wounds, open fractures with soft tissue defects, and coverage over split-thickness skin grafts. NPWT uniformly draws wounds closed by helping to remove interstitial fluid, which contains inflammatory and potentially infectious exudate that could impair healing. Recently in our practice, we have used NPWT in cases involving tenuous incisions, such as those used to access target structures during total ankle replacement or open repair of joint depression calcaneal fractures, in an effort to prevent hematoma or wound dehiscence. Although it is generally understood that NPWT can be efficacious and cost-effective for management of a wide range of lower extremity wounds, we also believe it to be beneficial in the management of low-energy trauma and elective hindfoot and ankle reconstructions, and feel that it has led to decreased pain, swelling, and time to healing in our patients. Based on our experience with ankle arthroplasty and the surgical management of hindfoot and ankle trauma, we believe that the use of NWPT in the immediate postoperative period is both safe and efficacious.
TL;DR: This study demonstrates that early weight bearing of the Lapidus arthrodesis can be performed without compromising correction or the rate of osseous union, and is the first study that specifically evaluates the early weight Bearing protocol after lapidus ArthrodesIS.
Abstract: The modified Lapidus arthrodesis involves fusion of the first tarsometatarsal, which typically takes about 6 weeks to consolidate. Postoperative protocols typically involve non-weight bearing until bone consolidation occurs, however, with a stable fixation construct, protected weight bearing can be initiated earlier than 6 weeks into the postoperative period. Studies specifically evaluating an early weight bearing protocol after lapidus arthrodesis do not exist; such a protocol is the focus of this investigation. A multicenter retrospective review of 80 feet in 76 patients who underwent a Lapidus arthrodesis by 2 different surgeons, involving a similar fixation technique and an early weight-bearing protocol, was performed. All patients were allowed protected weight bearing after the first postoperative visit, at approximately 2 weeks into the postoperative course. Patients began protected weight bearing at a mean 14.8 (95% CI 14.0, 15.6) days postoperative. All 80 feet proceeded to successful union (100% union), and the mean time to union was 44.5 days (95% CI 43.0, 46.0). No hardware was broken, and no complications requiring surgical revision were observed before solid boney fusion was achieved. Statistically significant (P < .001) improvements in the first intermetatarsal, hallux abductus, and lateral metatarsal angles were observed; and no cases of pathological first ray elevatus were encountered. The duration of time to bone healing in the cohort described in this article was similar to the rates described in previous reports describing Lapidus arthrodesis managed with a considerably longer duration of initial postoperative non-weight bearing. This study demonstrates that early weight bearing of the Lapidus arthrodesis can be performed without compromising correction or the rate of osseous union. This is the first study that specifically evaluates the early weight bearing protocol after lapidus arthrodesis.
TL;DR: A patient with severe irreducible open fracture dislocation of the ankle was admitted to the emergency department, and the tibialis posterior tendon between the distal tibia and fibula was located, thereby inhibiting the reduction.
Abstract: A patient with severe irreducible open fracture dislocation of the ankle was admitted to our emergency department. After wound irrigation and debridement, skeletal traction was applied to the calcaneus to minimize soft tissue injury and swelling. The patient was followed in traction for 1 week, after which reduction and fixation of the fibula was attempted but not achieved. We extended the incision distally, visualized the ankle, and located the tibialis posterior tendon between the distal tibia and fibula, thereby inhibiting the reduction. The tendon coursed into the tibiotalar joint anteriorly and pushed the talus anterolaterally. After manipulation of the tendon to its anatomically correct location, the ankle was easily reduced. The wound at the medial side was closed with a fasciocutaneous rotational flap. The ankle was then immobilized for 6 weeks postoperatively. The patient regained her full range of motion, and there were no problems with the tibialis posterior tendon, such as rupture or insufficiency. Isolated tibialis posterior tendon interposition between the distal tibiofibular and tibiotalar joints has rarely been reported, and can inhibit anatomical reduction of the fractured ankle.
TL;DR: The technical error in angular measurement was lower with the computer-assisted method, suggesting that this method is more reliable and the time taken was also reduced with this method.
Abstract: Radiographic angles are used to assess the severity of hallux valgus deformity, in preoperative planning, assessing postoperative outcomes, and in comparing results between interventions. The manual method to measure these angles has been shown to be prone to errors and to be time consuming. Computer programs are now available to assist in angular measurements. This study was undertaken to compare the reliability and time taken between the 2 methods. A total of 30 radiographs were used from a population of patients with hallux valgus deformity. The radiographs were digitized for computer-assisted measurements. The technical error of measurement (TEM) was calculated for intra- and interobserver data to assess the error in angular measurement with both methods. The technical error of measurement was lower with the computer-assisted method, suggesting that this method is more reliable. Furthermore, the time taken was also reduced with this method.
TL;DR: Based on the experience with the procedure, the single medial-incision subtalar and talonavicular joint arthrodesis is a useful alternative to triple arthropathy for the correction of hindfoot valgus deformity.
Abstract: Triple arthrodesis is commonly used to correct complex deformity with hindfoot valgus. The authors use an isolated medial incisional approach for subtalar and talonavicular joint arthrodesis to correct hindfoot deformity, including high degrees of hindfoot valgus. To assess outcomes achieved with this approach, we reviewed the records of 45 patients from the practices of 5 surgeons. Independent variables evaluated included patient age, primary pathology, use of biologic agents, operative time, time to union, and complications. The median patient age was 57 years (range, 14-78 years). Pathology leading to fusion included 27 (60%) posterior tibial tendon dysfunction, 6 (13.3%) tarsal coalition, 7 (5.5%) degenerative joint disease, 2 (4.4%) rheumatoid arthritis, and 1 (2.2%) each, with Charcot neuroarthropathy, multiple sclerosis, and poliomyelitis. Orthobiological materials were used in 27 (60.0%) of the patients. The median duration of surgery was 87 minutes (range, 65-164 minutes), and the median time to successful arthrodesis was 8 weeks (range, 6-20 weeks). A complication was observed in 6 (13.3%) of the patients, including 1 each of the following: painful calcaneal-cuboid joint, talar fracture, incision dehiscence, poor exposure that required abandonment of the procedure, elevated first ray, and painful fixation. None of the patients experienced a nonunion or an adverse event related to the medial neurovascular structures. Based on our experience with the procedure, the single medial-incision subtalar and talonavicular joint arthrodesis is a useful alternative to triple arthrodesis for the correction of hindfoot valgus deformity.
TL;DR: The current study demonstrated statistically significantly greater pullout strength for 3.5-mm bicortical screws when compared with 4.0-mm partially threaded cancellous screws used to fixate medial malleolar fractures in a cadaveric model.
Abstract: Displaced medial malleolus fractures are considered unstable and typically require open reduction and internal fixation for anatomic reduction and early joint range of motion. These fractures are usually fixated with either compression lag screws or tension band wiring depending on the fracture pattern, size of the distal fragment, and bone quality. When fracture fixation fails, it is typically in pullout strength. Failure of primary bone healing can result in nonunion, malunion, and need for revision surgery. The current study wished to explore a potentially stronger fixation technique in regard to pullout strength for medial malleolar fractures compared with traditional cancellous screws. This was a comparative study of the relative pullout strength of 2 fully threaded 3.5-mm bicortical screws versus 2 partially threaded 4.0-mm cancellous screws for the fixation of medial malleolar fractures. Ten fresh-frozen limbs from 5 cadavers, mean age 79 years (range of 65-97 years), were tested using the Instron 8500 Plus system. The median force recorded at 2 mm of distraction using unicortical partially threaded cancellous screws was 116.2 N (range 70.2 to 355.5N) compared with 327.6 N (range 117.5 to 804.3 N) in the fully threaded bicortical screw (P = .04). The unicortical screw fixation displayed only 64.53% of the median strength noted with the bicortical screw fixation at clinical failure. The current study demonstrated statistically significantly greater pullout strength for 3.5-mm bicortical screws when compared with 4.0-mm partially threaded cancellous screws used to fixate medial malleolar fractures in a cadaveric model.
TL;DR: In conclusion, metatarsal head resurfacing in combination with joint decompression, soft tissue mobilization, and debridement can achieve excellent results in grade II and III hallux rigidus.
Abstract: The treatment of advanced hallux rigidus remains controversial, with many authors discussing arthrodesis versus arthroplasty. The purpose of this study is to report mid-term outcomes after implantation of a motion-preserving metatarsal head-resurfacing prosthetic and to present our technical considerations and modifications to the published technique to further enhance the clinical benefit of the procedure. Thirty-two implantations were performed in 30 patients. Twenty-three patients were women, 9 men. The average age was 62.8 years (range, 39-86 years). Patients were graded at baseline according to Hattrup and Johnson and completed the American Orthopaedic Foot & Ankle Surgery metatarsophalangeal clinical rating system preoperatively and postoperatively and a patient satisfaction question at final follow-up. Seventy-two percent of implantations were grade III hallux rigidus and 28% were grade II. The average follow-up was 27.3 months (range, 12-43 months). The mean change score for the overall American Orthopaedic Foot & Ankle Surgery scale was 236.8% (SD = 146.62, confidence interval [CI] = 186-287.6). A similar result was achieved between grade II (250.9%, SD = 240.3, CI = 93.9-407.9) and grade III (231.3%, SD = 95.83, CI = 195.14-270.46). No implants were revised or removed, and all patients stated that they were happy with their outcome and would repeat the procedure again if needed. In conclusion, metatarsal head resurfacing in combination with joint decompression, soft tissue mobilization, and debridement can achieve excellent results in grade II and III hallux rigidus. Salvage arthrodesis remains an option if future revisions are indicated.
TL;DR: When combined with aggressive irrigation and debridement, the use of PMMA-ALC appears to be a beneficial adjunctive therapy for the treatment of foot and ankle soft tissue and osseous infections.
Abstract: Polymethylmethacrylate (PMMA) has been used in skeletal surgery for >40 years as a means of securing prosthetic implants and more recently was used as a delivery agent for local high-dose antibiotics to treat soft tissue and osseous infections The purpose of this study was to determine the role of PMMA antibiotic-loaded cement (PMMA-ALC) in combination with aggressive debridement for the treatment of foot and ankle soft tissue and osseous infections requiring operative intervention A retrospective observational cohort study of prospectively collected data was performed for all patients who underwent aggressive debridement with placement of PMMA-ALC for foot and ankle soft tissue and osseous infections between July 2006 and January 2009 There were 35 (29 men, 6 women) patients, 29 who had diabetes, with a mean age of 61 1 13 years (range, 16-86 years) A total of 36 feet/ankles (20 right, 16 left) were involved, and the infections were anatomically divided into 6 groups: (1) toes (n = 9), (2) metatarsalphalangeal joints (MTPJ) (first MTPJ, n = 5; fifth MTPJ, n = 5), (3) forefoot (n = 11), (4) rearfoot (n = 4), and (6) ankle/lower leg (n = 3) All patients had confirmed bacterial infection via microbiologic or pathologic analysis before PMMA-ALC insertion A total of 73 cultures were obtained at the time of PMMA-ALC removal, with 66 showing no bacterial growth (904%) and 7 positive for bacterial growth (96%) Methicillin-resistant Staphylococcus aureus was the most commonly cultured organism both preoperatively and postoperatively When combined with aggressive irrigation and debridement, the use of PMMA-ALC appears to be a beneficial adjunctive therapy for the treatment of foot and ankle soft tissue and osseous infections
TL;DR: Based on the high incidence of complications until these studies can be completed, routine use of isolated periarticular osteotomy of the first metatarsal for hallux rigidus should be performed with caution or not at all.
Abstract: Isolated periarticular osteotomy of the first metatarsal has been proposed for treatment of hallux rigidus due to the perceived ability to "decompress" the first metatarsophalangeal joint through axial shortening, as well as plantar displacement of the first metatarsal head to correct purported elevation. Additionally, isolated periarticular osteotomy of the first metatarsal has been proposed for treatment of hallux rigidus because of the perceived safety and efficacy. Furthermore, it has been proposed that undergoing isolated periarticular osteotomy of the first metatarsal does not prevent the ability to perform revision surgery. The author undertook a systematic review of electronic databases and other relevant sources to identify material relating to the clinical outcomes and need for surgical revision after isolated periarticular osteotomy of the first metatarsal for hallux rigidus. Information from peer-reviewed journals, as well as from non-peer-reviewed publications, abstracts and posters, and unpublished works, was also considered. In an effort to procure the highest quality studies available, studies were eligible for inclusion only if they involved consecutively enrolled patients undergoing isolated periarticular osteotomy of the first metatarsal for hallux rigidus, involved a prospective study design, included some form of objective and subjective data analysis, evaluated patients at a mean follow-up ≥12 months' duration, and included details of complications requiring surgical intervention. Four studies involving 93 isolated periarticular osteotomies of the first metatarsal followed up for a weighted mean of 18.6 months were identified that met the inclusion criteria. Peak dorsiflexion range of motion of the first metatarsophalangeal joint for the entire cohort of 93 patients increased 10.4°. The American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scoring Scale for the entire cohort of 93 patients increased 39 points from a weighted mean of 47.2 preoperatively to 86.2 postoperatively. For the two studies that included it, complete satisfaction or satisfaction with reservations was reported in only 55/75 (73.3%) patients, with the remainder being dissatisfied. A total of 21 (22.6%) procedures underwent surgical revision in the form of hardware removal (n = 8), lesser metatarsal surgery for intractable postoperative metatarsalgia (n = 7), no mention of revision procedure (n = 3), Keller resection arthroplasty (n = 2), and treatment of infection with revision of non-union (n = 1). Two studies specified the grade of hallux rigidus that underwent revision surgery after isolated periarticular osteotomy of the first metatarsal as follows: grade I, 16.7% (n = 3/18) and grade II, 30.5% (n = 18/59). Finally, a total of 30.5% (n = 18/59) of patients developed postoperative metatarsalgia or stress fracture. Additional prospective studies involving validated subjective and objective outcome measurement tools with computerized gait analysis and long-term follow-up after isolated periarticular osteotomy of the first metatarsal for the various grades of hallux rigidus, as well as with comparison with isolated cheilectomy and Valenti arthroplasty, would be beneficial. Based on the high incidence of complications until these studies can be completed, routine use of isolated periarticular osteotomy of the first metatarsal for hallux rigidus should be performed with caution or not at all.
TL;DR: What is believed to be the first published case of anaplastic large T-cell lymphoma associated with a stainless steel fixation plate that was implanted several years earlier for repair of a tibial fracture is described.
Abstract: On occasion, the placement of orthopedic prosthetic components or stabilization hardware leads to surgical site infections, in some cases presenting at a point in time distant from the surgical procedure. Although infectious complications are the most common etiology for surgical site pain and inflammation, malignancies can also develop around prosthetic devices and metallic implants. When encountered, such malignancies are most often sarcoma, but rarely B-cell non-Hodgkin's lymphoma has also been described. In this article, we describe what we believe to be the first published case of anaplastic large T-cell lymphoma associated with a stainless steel fixation plate that was implanted several years earlier for repair of a tibial fracture. Appropriate to this case, we review the medical literature on the association of orthopedic implants with the development of neoplasm, along with the theorized pathogenic mechanisms leading to such an association.
TL;DR: The use of a temporary Kirschner-wire as a third point of fixation may enable immediate protected weight bearing, by minimizing load placed on the crossed lag screw construct, in patients undergoing modified Lapidus arthrodesis.
Abstract: First metatarsocuneiform arthrodesis (Lapidus procedure) can provide powerful correction of mild to moderate hypermobile or severe hallux valgus, although a period of non-weight bearing may be necessary. The purpose of this retrospective investigation was to compare patients who underwent a modified Lapidus arthrodesis with 2 screws plus an additional "neutralization" Kirschner-wire with immediate partial weight-bearing in a removable boot, with a control group without the Kirschner-wire who were non-weight bearing for 6 weeks in a short leg cast. A total of 41 consecutive patients from January 2004 to January 2007 were included in this comparative cohort study. There were no significant radiographic changes between immediate and final 6-month postoperative radiographs in regard to first intermetatarsal angle (degree) and first ray elevation measurements (first to second metatarsal head elevation [mm] and Seiberg index [mm]) within groups (P = .49, .47, and .54, and 95% confidence intervals of [-2.1, 1.2], [-0.32, 2.03], and [-0.82, 0.44], respectively) or between groups (P = .259, .67, and .083, and 95% confidence intervals of [-4.2, 1.2], [-1.39, 0.91], and [-1.77, 0.12], respectively), as computed with paired 2-sample t tests. Stratified Mantel-Haenszel analyses revealed both groups to be comparable relative to severity of deformity, gender, age, smoking history, perioperative immunosuppressant use, and other comorbidities. No nonunions or malunions where observed in either group. The use of a temporary Kirschner-wire as a third point of fixation may enable immediate protected weight bearing, by minimizing load placed on the crossed lag screw construct, in patients undergoing modified Lapidus arthrodesis.
TL;DR: Findings support the use of APD, alone or with PRPFM, to augment Achilles tendon repair in a sheep model.
Abstract: The primary goal of this study was to evaluate a cross-linked acellular porcine dermal patch (APD), as well as platelet-rich plasma fibrin matrix (PRPFM), for repair of acute Achilles tendon rupture in a sheep model. The 2 surgically transected tendon ends were reapproximated in groups 1 and 2, whereas a gap was left between the tendon ends in group 3. APD was used to reinforce the repair in group 2, and autologous PRPFM was used to fill the gap, which was also reinforced with APD, in group 3. All sheep were humanely euthanized at 24 weeks after the repair, and biomechanical and histological testing were performed. Tensile strength testing showed a statistically significant difference in elongation between the operated limb and the unoperated contralateral limb in groups 1 and 3, but not in group 2. All operated tendons appeared healed with no apparent fibrosis under light and polarized microscopy. In group 1, all surgical separation sites were identifiable, and healing occurred via increasing tendon thickness. In group 2, healing occurred with new tendon fibers across the separation, without increasing tendon thickness in 2 out of 6 animals. Group 3 showed complete bridging of the gap, with no change in tendon thickness in 2 out of 6 animals. In groups 2 and 3, peripheral integration of the APD to tendon fibers was observed. These findings support the use of APD, alone or with PRPFM, to augment Achilles tendon repair in a sheep model.
TL;DR: Cheilectomy should be considered a first-line surgical treatment for hallux rigidus, and there remains a need for methodologically sound prospective cohort studies that focus on the use of cheilectomies for specific grades of hallUX rigidus.
Abstract: Isolated cheilectomy has been proposed for treatment of hallux rigidus due to the perceived safety, efficacy, and ability to revise with repeat cheilectomy, implant or interpositional arthroplasty, or arthrodesis. A systematic review was undertaken to better understand the need for surgical revision after isolated cheilectomy for hallux rigidus. Studies were eligible for inclusion only if they involved consecutively enrolled patients undergoing isolated cheilectomy or involved revision surgery of the first metatarsophalangeal joint after isolated cheilectomy, evaluated patients at mean follow-up > or = 12 months' duration, and included details of complications. Twenty-three studies, describing 706 cheilectomies, met the inclusion criteria, with 62 (8.8%) undergoing surgical revision in the form of arthrodesis (n = 23), no mention of revision procedure (n = 17), interpositional arthroplasty (n = 13), silicone implant arthroplasty (n = 4), Keller resection arthroplasty (n = 3), or repeat cheilectomy (n = 2). Twelve studies specified the grade of hallux rigidus as: 103 (19.9%) grade 1, 210 (40.6%) grade II, 189 (36.6%) grade III, and 15 (2.9%) grade IV. Six studies indicated the number of cheilectomies that required revision surgery as: 2 (20%) grade I, 8 (14.8%) grade II, 12 (9.1%) grade III, and 5 (55.6%) grade IV. These results make clear the low incidence of revision surgery after cheilectomy for hallux rigidus. Therefore, cheilectomy should be considered a first-line surgical treatment for hallux rigidus. There remains a need for methodologically sound prospective cohort studies that focus on the use of cheilectomy for specific grades of hallux rigidus.
TL;DR: Primary arthrodesis provides predictable radiographic outcomes and effective correction for patients with differing severity of hallux abductovalgus deformity and arthritis of the first metatarsophalangeal joint.
Abstract: The purpose of this study was to evaluate the radiographic outcomes of primary metatarsophalangeal joint arthrodesis for hallux abductovalgus deformities. Between January 2004 and March 2009, 56 consecutive patients (58 feet) underwent primary arthrodesis of the metatarsophalangeal joint (MTPJ) for severe hallux abductovalgus deformity and or hallux rigidus. Results were assessed by primary radiographic outcome measurements (hallux valgus and first-second intermetatarsal angle). Overall, the mean hallux valgus (HA) angle improved significantly from 31.9° to 13.4° (P < .01). The mean first-second intermetatarsal (IM) angle correction was also signficantly reduced from 14.0° to 9.7° (P < .01). When separated by deformity group (mild, moderate, and severe), the mean hallux valgus and first-second intermetatarsal angles demonstrated statistically significant correction in all groups when comparing preoperative and postoperative values (P < .01). Primary arthrodesis provides predictable radiographic outcomes and effective correction for patients with differing severity of hallux abductovalgus deformity and arthritis of the first metatarsophalangeal joint. A separate proximal osteotomy for severe metatarsus primus varus correction may not be necessary because of the correction achieved at the metatarsophalangeal joint arthrodesis level. The results of this study demonstrate that as the severity of the preoperative deformity increases, the amount of postoperative radiographic (HA and IM angle measurement) correction after MTPJ arthrodesis will improve correspondingly.
TL;DR: The syndesmotic ligaments are debrided and reduced under arthroscopic guidance and anatomical reduction of the syndesmosis can be achieved.
Abstract: The distal tibiofibular syndesmosis provides stability to the ankle mortise, and it is composed of the anterior inferior tibiofibular, posterior inferior tibiofibular, interosseous, and inferior transverse tibiofibular ligaments and the interosseous membrane. Subacute or chronic syndesmosis injuries can present after missed diagnosis in the acute period or after failed or inadequate nonoperative management. It can result in chronic ankle pain and progressive degeneration of the ankle. Reconstructive options for chronic syndesmosis disruption include arthroscopic debridement and screw fixation, arthrodesis of the syndesmosis, advancement of the anterior tibiofibular ligament, reconstruction of the interosseous and anterior inferior tibiofibular ligament, or tri-ligamentous reconstruction of the syndesmosis. We describe a minimally invasive technique of nearly anatomical reconstruction of the 3 syndesmotic ligaments. The syndesmosis is debrided and reduced under arthroscopic guidance and anatomical reduction of the syndesmosis can be achieved. Although we describe this technique for surgeons to consider, we recognize that a thorough clinical review of the method, complete with objective and subjective clinical outcome measurements, is warranted before widespread use of the technique.
TL;DR: This prospective study provided further evidence of the success of dorsal cheilectomy as a treatment for hallux rigidus and demonstrated the potential usefulness of the MOXFQ in assessing surgical outcomes in foot surgery.
Abstract: Compared with other surgical procedures for hallux rigidus, dorsal cheilectomy involves relatively less bone removal, maintains joint motion, and leaves the potential for further salvage surgery. The Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ) has a maximum score of 64 (worst foot health) and has been endorsed by the British Foot and Ankle Society to measure surgical outcome. We prospectively assessed patient-reported outcomes after dorsal cheilectomy for hallux rigidus using the MOXFQ. Patients were deemed suitable for dorsal cheilectomy if they had painful restriction of terminal dorsiflexion, with absence of pain in the mid-range of passive movement, and radiographic evidence of dorsal osteophytosis. Twenty-five patients with a mean age of 62 years (range, 39-80 years), including 17 (68%) women, underwent dorsal cheilectomy for hallux rigidus. The mean preoperative MOXFQ score was 33.0 (95% confidence interval = 27.4-38.6), and, at a mean of 17 months (range, 9-27 months) follow-up, the mean postoperative score was 9.6 (95% confidence interval = 6.0-13.2). Eighty-four percent of patients experienced clinically significantly improved walking domain, 68% in the social domain, and 59% in the pain domain of the MOXFQ. Four patients failed cheilectomy, including 3 who subsequently underwent arthrodesis for persistent pain and 1 who experienced no improvement in any domain of the MOXFQ. This prospective study provided further evidence of the success of dorsal cheilectomy as a treatment for hallux rigidus and demonstrated the potential usefulness of the MOXFQ in assessing surgical outcomes in foot surgery.
TL;DR: The intended emphasis of this investigation is to evaluate the sesamoid position in multiple planes relative to a stationary anatomical landmark following first metatarsal osteotomy for the surgical correction of hallux abductovalgus deformity.
Abstract: The standard classification system used to measure the sesamoids in the evaluation of hallux abductovalgus is a uniplanar description of a multiplanar deformity. Additionally, it cannot accurately describe a true measure of sesamoid positional change in the perioperative period because the first metatarsal is laterally transposed during corrective surgery. The intended emphasis of this investigation is to evaluate the sesamoid position in multiple planes relative to a stationary anatomical landmark following first metatarsal osteotomy for the surgical correction of hallux abductovalgus deformity. A retrospective radiographic review of 46 feet in 38 patients demonstrated statistically significant (P < .001) differences between preoperative and postoperative values for the first intermetatarsal angle, hallux abductus angle, sesamoid rotation angle, tibial sesamoid position, and tibial sesamoid grade. However, there was no significant difference in the sesamoid position in both the transverse (P = .07) and frontal (P = .29) planes when measured relative to the stationary second metatarsal. Based on the preceding results, the appropriate expected surgical outcome of hallux abductovalgus correction may be to relocate the first metatarsal on top of the relatively immobile sesamoids.
TL;DR: Flexor tenotomy is a simple treatment with low complications and recurrence rates and provides good-to-excellent functional outcomes in treating flexible clawing of the toes and the associated ulceration.
Abstract: Ulcers of the toes may cause a severe physical burden, especially in patients with diabetes, in whom they occur most frequently. Several treatments have been proposed for the underlying anatomical abnormalities, but they vary in effectiveness. We evaluated our results in using flexor tenotomy to treat ulcers with underlying flexible clawing of the toes. For 42 toes from 23 patients, 15 of whom were diabetic, all ulcers healed. The mean healing time was 4 weeks (range, 1-8 weeks), the mean follow-up was 11 months (range, 1-27 months), and one recurrence and one complication occurred. Postoperative American Orthopaedic Foot Ankle Society Midfoot scores were available for 15 patients: the mean was 77 (range, 43-100). The mean visual analogue scale (VAS) for patient satisfaction increased from 3.9 points (range, 0-10 points) preoperatively to 7.7 (range, 5-10 points) postoperatively. Flexor tenotomy is a simple treatment with low complications and recurrence rates and provides good-to-excellent functional outcomes in treating flexible clawing of the toes and the associated ulceration.