Background. Kirschner wire (K-wire) fixation for correction of hammertoe deformity is the gold standard for hammertoe surgery fixation, the current study compares it to percutaneous surgery with 3M Coban dressings. Methods. All hammertoe corrections performed were retrospectively reviewed. For the K-wire fixation group: resection arthroplasty of the proximal interphalangeal joint was performed and fixed with a K-wire. The percutaneous technique used involved percutaneous diaphyseal osteotomy of the middle and proximal phalanges combined with tendon release. The toes are then wrapped in 3M Coban dressing for 3 weeks. Follow-up duration, preoperative diagnosis, pin duration, concomitant procedures, visual analogue scale (VAS) pain, recurrence rates, and complications were reviewed and analyzed. A total of 352 patients (87 percutaneous/265 open), in whom 675 hammertoes (221 percutaneous/454 open) were corrected. There were 55.9% females, with an average age of 52.8 years, followed for 6 months. The percutaneous group had more diabetics and multiple toes surgery. Results. Complications of the open surgery group included 5.5% pin migrations, 4.5% infections, and 8 (3%) had impaired wound healing. There were 6.2% recurrent deformities and 2.6% toes were revised. Malalignment was noted in 3.3% toes. Vascular compromise occurred in 0.5%, with 0.25% amputated. Complications of the percutaneous surgery group included 18.4% cases of impaired healing and 2.3% infection. Deep tissue dehiscence occurred in 4.5% of open surgery patients. VAS score decreased in both groups with a more pronounced decline in the percutanteous group (2 ± 2.1 vs 0.5 ± 1.6). The per toe infection rate of patients undergoing open hammertoe correction was 5.3% was significantly higher than with the percutaneous correction group, which was 2.2%. Conclusions. K-wire fixation and percutaneous surgery have similar abnormal healing rates, alignment and patient satisfaction but the latter technique has fewer infections.
Levels of Evidence: Level III: Prospective case series with noncontamporenous cohorts
Background. Articular cartilage lesions of the talus remain a challenging clinical problem because of the lack of natural regeneration and limited treatment options. Microfracture is often the first-line therapy, however lesions larger than 1.5 cm2 have been shown to not do as well with this treatment method. Methods. The objective of this retrospective study was to evaluate the outcomes of iliac crest bone marrow aspirate concentrate/collagen scaffold (ICBMA) and particulated juvenile articular cartilage (PJAC) for larger articular cartilage lesions of the talus. Fifteen patients undergoing ICBMA or PJAC for articular cartilage lesions of the talus from 2010 to 2013 were reviewed. Twelve patients, 6 from each treatment option, were included in the study. American Orthopaedic Foot and Ankle Surgeons (AOFAS), Foot and Ankle Ability Measure (FAAM), and Short Form–12 (SF-12) outcome scores were collected for each patient. Results. The mean age was 34.7 ± 14.8 years for ICBMA and 31.5 ± 7.4 years for PJAC. Lesion size was 2.0 ± 1.1 cm2 for ICBMA and 1.9 ± 0.9 cm2 for PJAC. At a mean follow-up of 25.7 months (range, 12-42 months), the mean AOFAS score was 71.33 for ICBMA and 95.83 for PJAC ( P = .019). The FAAM activities of daily living subscale mean was 77.77 for ICBMA and 97.02 for PJAC ( P = .027). The mean FAAM sports subscale was 45.14 for ICBMA and 86.31 for PJAC ( P = .054). The SF-12 physical health mean was 47.58 for ICBMA and 53.98 for PJAC ( P = .315). The SF-12 mental health mean was 53.25 for ICBMA and 57.8 for PJAC ( P = .315). One patient in treated initially with ICBMA underwent revision fixation for nonunion of their medial malleolar osteotomy, which ultimately resulted in removal of hardware and tibiotalar arthrodesis at 2 years from the index procedure. Conclusion. In the present analysis, PJAC yields better clinical outcomes at 2 years when compared with ICBMA for articular cartilage lesions of the talus that were on average greater than 1.5cm2.
Levels of Evidence: Therapeutic, Level IV: Retrospective, case series
Background. This study uses the American College of Surgeons National Trauma Data Bank (NTDB) to update the field on the demographics, injury mechanisms, and concurrent injuries among a national sample of patients admitted to the hospital department with calcaneus fractures. Methods. Patients with calcaneus fractures in the NTDB during 2011-2012 were identified and assessed. Results. A total of 14 516 patients with calcaneus fractures were included. The most common comorbidity was hypertension (18%), and more than 90% of fractures occurred via traffic accident (49%) or fall (43%). A total of 11 137 patients had concurrent injuries. Associated lower extremity fractures had the highest incidence and occurred in 61% of patients (of which the most common were other foot and ankle fractures). Concurrent spine fractures occurred in 23% of patients (of which the most common were lumbar spine fractures). Concurrent nonorthopaedic injuries included head injuries in 18% of patients and thoracic organ injuries in 15% of patients. Conclusion. This national sample indicates that associated injuries occur in more than three quarters calcaneus fracture patients. The most common associated fractures are in close proximity to the calcaneus. Although the well-defined association of calcaneus fractures with lumbar spine fractures was identified, the data presented highlight additional strong associations of calcaneus fractures with other orthopaedic and nonorthopaedic injuries.
Levels of Evidence: Prognostic, Level III: Retrospective review of a prospectively collected cohort
Background. Refractory cases of Achilles tendinopathy amenable to surgery may include reattachment of the tendon using suture anchors. However, there is paucity of information describing the optimal insertion angle to maximize the tendon footprint and anchor stability in the calcaneus. The purpose of this investigation is to compare the fixation strength of suture anchors inserted at 90° and 45° (the Deadman’s angle) relative to the primary compressive trabeculae of the calcaneus. Methods. A total of 12 matched pairs of adult cadaveric calcanei were excised and potted to approximate their alignment in vivo. Each pair was implanted with 5.5-mm bioabsorbable suture anchors placed either perpendicular (90°) or oblique (45°) to the primary compressive trabeculae. A tensile load was applied until failure of anchor fixation. Differences in failure load and stiffness between anchor fixation angles were determined by paired t-tests. Results. No significant differences were detected between perpendicular and oblique suture anchor insertion relative to primary compressive trabeculae in terms of load to failure or stiffness. Conclusion. This investigation suggests that the fixation strength of suture anchors inserted perpendicular to the primary compression trabeculae and at the Deadman’s angle are possibly comparable.
Levels of Evidence: Biomechanical comparison study
Background. Despite the low incidence of deep vein thrombosis (DVT) in foot and ankle surgery, some authors report a high incidence of symptomatic DVT following Achilles tendon rupture. The purpose of this study was to identify DVT risk factors inherent to Achilles tendon repair to determine which patients may benefit from prophylaxis. Methods. One hundred and thirteen patient charts were reviewed following elective and nonelective Achilles tendon repair. For elective repair of insertional or noninsertional Achilles tendinopathy, parameters examined included lateral versus prone positioning and the presence versus absence of a flexor hallucis longus transfer. For nonelective repair, acute Achilles tendon ruptures were compared to chronic Achilles tendon ruptures. Results. Of 113 Achilles tendon repairs, 3 venous thromboembolism (VTE) events (2.65%) occurred including 2 pulmonary emboli (1.77%). Seventeen of these repairs were chronic Achilles tendon ruptures, and all 3 VTE events (17.6%) occurred within this subgroup. Elevated body mass index was associated with VTE in patients with chronic Achilles ruptures although this did not reach significance (P = .064). No VTE events were reported after repair of 28 acute tendon ruptures or after 68 elective repairs of tendinopathy. Two patients with misdiagnosed partial Achilles tendon tears were excluded because they experienced a VTE event 3 weeks and 5 weeks after injury, prior to surgery. Conclusion. In our retrospective review, chronic Achilles ruptures had a statistically significant higher incidence of VTE compared with acute Achilles ruptures (P = .048) or elective repair (P = .0069). Pharmaceutical anticoagulation may be considered for repair of chronic ruptures. Repair of acute ruptures and elective repair may not warrant routine prophylaxis due to a lower incidence of VTE.
Levels of Evidence: Prognostic, Level III: Case Control Study
Common surgical treatment of first tarsal-metatarsal arthritis is by first metatarsocuneiform joint arthrodesis. While crossed-screw and locking plate fixation are the most widely used methods, a novel construct was designed to alleviate soft tissue irritation while still providing stable fixation. Using anatomic first metatarsal and medial cuneiform composites, we compared 3 arthrodesis implants (crossed-screw, dorsal locking plate, and IO Fix) under 2 cyclic bending loading scenarios (cantilever and 4-point bending). Additionally, the optimal orientation (plantar-dorsal or dorsal-plantar) of the IO Fix construct was determined. Failure load, diastasis, joint space angle, and axial and angular stiffness were determined. Both crossed-screw fixation and the IO Fix constructs experienced significantly higher failure loads than the dorsal locking plate during both loading scenarios. Additionally, they had lower plantar diastasis and joint space angle at failure than the plate. Moreover, the plantar-dorsal IO Fix construct was significantly stiffer than the crossed-screw during cantilever bending. Finally, the plantar-dorsal orientation of the IO Fix device had higher failure load and lower diastasis and angle at failure than in the dorsal-plantar orientation. The results suggest that the IO Fix system can reduce motion at the interfragmentary site and ensure compression for healing comparable to that of the crossed-screw fixation.
Levels of Evidence: Level V: Bench testing
In ankle fractures, the result of a gravity stress radiographic examination is clinically used to determine if a patient may need surgical intervention. The purpose of this study is to report the results of a gravity stress examination in the normal patient population. Fifty study participants were prospectively enrolled and complete ankle radiographs were obtained, including a nonweightbearing gravity stress examination. The mean medial clear space in the gravity stress view was 3.6 mm. This compared to a mean medial clear space of 3.3 mm, and 3.1 mm in the anteroposterior and mortise views. These values were statistically significantly different from the gravity stress view ( P = .006 and P < .001, respectively). There was no statistically significant difference between the talar tilt as measured on the anteroposterior and gravity stress radiographs ( P = .22). No participant had medial clear space widening with gravity stress to more than 5.2 mm or an increase in their widening by more than 0.2 mm. In conclusion, this study helps guide surgeons by providing normative radiographic data for a gravity stress examination and supports the notion that measureable medial clear space widening or talar tilt on gravity stress examination represents an unstable injury.
Level of Evidence: Level II: Prospective
Background. Ankle fractures are common and represent a significant burden to society. We aim to report the rate of union as determined by clinical and radiographic data, and to identify factors that predict time to union. Methods. A cohort of 112 consecutive patients with isolated, closed, operative malleolar ankle fractures treated with open reduction and internal fixation was retrospectively reviewed for time to clinical union. Clinical union was defined based on radiographic and clinical parameters, and delayed union was defined by time to union >12 weeks. Injury characteristics, patient factors and treatment variables were recorded, and statistical techniques employed included the Chi-square test, the Student’s T-test, and multivariate linear regression modeling. Results. Forty-two (37.5%) of patients who achieved union did so in less than 12 weeks, and 69 (61.6%) of these patients demonstrated delayed union at a mean of 16.7 weeks (range, 12.1-26.7 weeks), and the remaining patient required revision surgery. Factors associated with higher rates of delayed union or increased time to union included tobacco use, bimalleolar fixation, and high energy mechanism (all p<0.05). In regression analysis, statistically significant negative predictors of time to union were BMI, dislocation of the tibiotalar joint, external fixation for initial stabilization and delay of definitive management (all p<0.05). Conclusion. Patient characteristics, injury factors and treatment variables are predictive of time to union following open reduction and internal fixation of closed ankle fractures. These findings should assist with patient counseling, and help guide the provider when considering adjunctive therapies that promote bone healing.
Levels of Evidence: Prognostic, Level IV: Case series
Background. The Internet has been reported to be the first informational resource for many fellowship applicants. The objective of this study was to assess the accessibility of orthopaedic foot and ankle fellowship websites and to evaluate the quality of information provided via program websites. Methods. The American Orthopaedic Foot and Ankle Society (AOFAS) and the Fellowship and Residency Electronic Interactive Database (FREIDA) fellowship databases were accessed to generate a comprehensive list of orthopaedic foot and ankle fellowship programs. The databases were reviewed for links to fellowship program websites and compared with program websites accessed from a Google search. Accessible fellowship websites were then analyzed for the quality of recruitment and educational content pertinent to fellowship applicants. Results. Forty-seven orthopaedic foot and ankle fellowship programs were identified. The AOFAS database featured direct links to 7 (15%) fellowship websites with the independent Google search yielding direct links to 29 (62%) websites. No direct website links were provided in the FREIDA database. Thirty-six accessible websites were analyzed for content. Program websites featured a mean 44% (range = 5% to 75%) of the total assessed content. The most commonly presented recruitment and educational content was a program description (94%) and description of fellow operative experience (83%), respectively. Conclusions. There is substantial variability in the accessibility and quality of orthopaedic foot and ankle fellowship websites. Clinical Relevance. Recognition of deficits in accessibility and content quality may assist foot and ankle fellowships in improving program information online.
Levels of Evidence: Level IV
Arthrodesis of the first metatarsal cuneiform joint, or Lapidus procedure, is a widely accepted treatment for hallux valgus. Recent studies have focused on comparing various constructs for this procedure both in the laboratory and clinical settings. The current study compared in a cadaveric model the strength of 2 constructs. The first construct utilized a medially applied low-profile locking plate and an interfragmentary screw directed from plantar-distal to dorsal-proximal. The second construct consisted of a plantarly applied plate with a compression screw placed through the plate from plantar-distal to dorsal-proximal. The ultimate load to failure for the 2 groups tested was 255.38 ± 155.38 N and 197.48 ± 108.61 N, respectively (P = .402). There was no significant difference found between the 2 groups with respect to ultimate load to failure, stiffness of the construct, or moment at time of failure. In conclusion, the medially applied plate with plantar interfragmentary screw appears to be stronger than the plantar Lapidus plate tested for first metatarsal cuneiform arthrodesis, though this difference did not reach statistical significance.
Levels of Evidence: Level V: Biomechanical Study
Introduction. Historically, Achilles tendon repairs and other surgeries about the hindfoot have demonstrated a significantly higher rate of wound healing complications and surgical site morbidity. The purpose of this study was to evaluate the comprehensive complication profile and risk factors for adverse short-term, clinical outcomes after primary repair of Achilles tendon ruptures. Methods. Between the years 2005 and 2014, all cases of primary Achilles tendon repair (Current Procedural Terminology code 27650) entered into the National Surgical Quality Improvement Project (NSQIP) database were extracted for analysis. Primary outcomes of interest were rates of total complication, reoperation, and rerupture within 30 days of index surgery. Independent risk factors associated with these selected endpoints were assessed with chi-square and logistic regression analysis and odds ratios with 95% confidence intervals were used to express relative risk. Results. Of 1626 patients with an average age of 44 years (SD 13.3), the average ASA classification was 1.69 and hypertension (20.7%), morbid obesity (8.3%), and diabetes (4.9%) were among the most common medical comorbidities. A total of 28 (1.7%) patients sustained perioperative complications, including 1.3% with local complications (0.7% superficial wound infection, 0.4% wound disruption) and no cases of peripheral nerve injury or early repair failure. Systemic complications occurred in 0.4%, most commonly with deep venous thrombosis or nonfatal thromboembolism. Preoperative albumin was independently associated with an increased risk of local wound complications (odds ratio [OR] 28.67; 95% CI 1.42-579.40; P = .029). Chronic obstructive pulmonary disease (OR 22.33, 95% CI 2.49-199.81; P = .006) and bleeding disorder (OR 14.83, 95% CI 1.70-129.50; P = .015) were more likely to result in a systemic complication, and preoperative creatinine correlated with an increased risk of any complication (OR 6.11, 95% CI 1.15-32.34; P = .033). In total there were 5 (0.3%) readmissions with 2 (0.1%) unplanned reoperations attributed to local wound complications. Conclusion. Among a broad-based demographic of the United States, the rate of local wound complications was exceedingly low in the short-term perioperative period, although this risk may be significantly magnified with subtle decreases in albumin levels. Preoperative risk stratifications should carefully scrutinize for subtle abnormalities in nutritional parameters and renal function prior to undergoing Achilles surgery.
Levels of Evidence: Therapeutic, Level II: Prospective, comparative trial
Background. The Trimed Medial Malleolar Sled is a newer device designed to treat medial malleolus fracture. The purpose of this study was to compare the outcome of medial malleolar fractures treated with the sled and conventional malleolar screws. Methods. After obtaining an institutional review board approval, we conducted a retrospective study to identify all skeletally mature patients who sustained an ankle fracture with medial malleolar involvement treated with the sled and we identified a matched cohort treated with conventional malleolar screws. The patients were divided into 2 groups: group A included patients treated with malleolar screws and group B included patients treated with the sled device. The outcomes measured included rate of union, implant removal, and pain over the implant site. Results. Eighty-five medial malleolar ankle fractures were divided into 2 groups: group A included patients (n = 64) treated with malleolar screws and group B included patients (n = 21) treated with the sled device. In group A (n = 64), 62 patients (96.8%) achieved radiological union with a mean union rate of 11 weeks and 10 (15%) patients underwent repeat surgery for implant removal of which 3 patients (4.6%) had pain specifically over the medial implant. In group B (n = 21), all of the patients (100%) achieved radiological union with a mean union rate of 10.8 weeks and 3 patients (14.2%) underwent repeat surgery of which 1 (4.7%) was related to the medial pain. There is no significant difference between the groups for the outcomes measured, including rate of union ( P = .93), visual analog scale score for pain ( P = .07), implant removal ( P = .41), and pain over the implant site ( P = .88). Conclusion. Based on the data from our study, we conclude that there are no major differences between the sled devices and conventional screws relating to union rate and complications.
Levels of Evidence: Level III: Observational study.
We compared the results of radiofrequency thermal lesioning (RTL) and extracorporeal shockwave therapy (ESWT) in patients with chronic plantar fasciitis. This prospective study included 56 patients diagnosed with plantar fasciitis who had complaints for ≥6 months: 40 (group 1) underwent ESWT and 16 (group 2) underwent RTL. The presence of calcaneal spurs was investigated with imaging studies. All patients were followed up clinically at baseline and 1, 3, and 6 months after treatment. Clinical evaluations were performed by the visual analog scale (VAS) and the modified Roles-Maudsley (RM) scoring system. There was no significant difference in the age, sex, body mass index, and side of involvement between the groups (all P > .05). Radiographic evaluation showed calcaneal spurs in 22 patients (55%) in group 1 and 7 patients (43%) in group 2. There was no significant difference in the baseline and posttreatment values between the groups; however, group 2 had significantly different RM values at 1 month than group 1 (P < .05). In both groups, the VAS scores significantly decreased at 1, 3, and 6 months after treatment (P < .05). The RM scores at 1, 3, and 6 months after treatment significantly decreased in both groups, except for the RM values at 1 month after treatment in group 1 (P < .05). Our study results suggest that RTL and ESWT are safe and effective treatments in patients with chronic plantar fasciitis.
Levels of Evidence: Level II: Therapeutic study
Introduction. Although Eichenholtz and the Schon systems are commonly used to evaluate foot Charcot arthropathy on radiographs, a novel system with expanded characterization may have added benefit. Methods. Patients with Charcot arthropathy and foot radiographs were grouped in nonsurgical group 1 (imaging sets at minimum 2-year interval) and surgical group 2 (imaging preceding fusion and/or amputation). Radiographs were scored with Eichenholtz and Schon systems, and a novel scoring system (summation of 0-3 rank for bone density, distention/swelling, debris, disorganization, and dislocation/subluxation). Summative scores of the 2 groups were compared. Differences in scores of each system from serial images of group 1 were compared and average scores from each of the systems for preoperative imaging sets of group 2 were compared. Results. A total of 111 patients were included (group 1, 19 patients; group 2, 92 patients). The novel system provided a broad numerical characterization of the radiographs (range 1-15). Summative scores of the novel system for groups 1 and 2 were statistically different with lower median score in the nonsurgical group (nonsurgical median score 6 vs surgical median score 9). Individual characteristic scores from 4 (distention, debris, disorganization, and dislocation) of 5 categories for the novel system were statistically different, with lower scores for the nonoperative group. The narrower numerical scores from the Eichenholtz and Schon systems did not yield statistically significant results. Conclusion. The novel scoring system provides a broad numerical description of radiographic findings in Charcot arthropathy of the foot and has potential advantage for surgical predictive value.
Level of Evidence: Level IV: Retrospective
Background. Total ankle arthroplasty (TAA) provides an alternative to ankle fusion (AF). The purpose of this study is to (1) determine the extent of TAA regionalization, as well as examine the growth of TAA performed at high-, medium-, and low-volume New York State institutions and (2) compare this regionalization and growth with AF. Methods. The New York Statewide Planning and Research Cooperative System (SPARCS) administrative data were used to identify 737 primary TAA and 7453 AF from 2005 to 2014. The volume of TAA and AF surgery in New York State was mapped according to patient and hospital 3-digit zip code. Results. The number of TAA per year grew 1500% (from 11 to 177) from 2005 to 2014, while there was a 35.6% reduction (from 895 to 576) in yearly AF procedures. TAA recipients were widely distributed throughout the state, while TAA procedures were regionalized to a few select metropolitan centers. AF procedures were performed more uniformly than TAA. The number of TAA has continued to increase at high- (15 to 91) and medium-volume (14 to 67) institutions where it has decreased at low-volume institutions (44 to 19). Conclusion. The increased utilization of TAA is attributed to relatively few high-volume centers located in major metropolitan centers.
Levels of Evidence: Level IV: well-designed case-control or cohort studies
Background. The hypothesis of this study is that a sprain or tear of 1 or more of the 3 syndesmotic ligaments will result in a significant change in the osseous anatomy relationship when comparing injured to uninjured syndesmosis. Our secondary objective was to determine whether injuries to the syndesmosis as diagnosed on magnetic resonance imaging (MRI) could be found using static imaging. Methods. This is a descriptive radiological study of ankle MRI reports over a 12-year period, from 2 different institutions, and divided in two groups: normal and injured syndesmotic ligaments. A series of 6 lengths and 2 angles were measured on MRI axial views that describe the rotation, lateral, and anteroposterior translational relation between the distal tibia and fibula. Parameters from injured and uninjured ankles were compared using Student’s t-test. Results. Fifty uninjured syndesmosis were compared to 64 injured syndesmoses. The majority of syndesmosis injuries concerned either an anterior inferior tibiofibular ligament sprain or tear. There was a significant difference in the anatomic position of the tibia and the fibula between injured and uninjured syndesmosis. Conclusions. The anterior inferior tibiofibular ligament is the most commonly injured ligament in the syndesmosis in sports injury and results in subtle variations in the syndesmotic anatomy, which plain radiographs cannot assess. Because of the previously validated computed tomography scan measurement, this study demonstrates a potential to identify syndesmotic injury on other more accessible imaging modalities, such as computed tomography scan, by using a well-defined measurement system.
Levels of Evidence: Diagnostic, Level III : Retrospective, Radiologic Study
Introduction. Structural fresh osteochondral allograft transfer is an appropriate treatment option for large osteochondral lesions of the talus (OLTs), specifically lesions involving the shoulder of the talus. Sparse literature exists regarding functional outcome following this surgery in high-demand populations. Materials and Methods. Over a 2-year period, a single surgeon performed 8 structural allograft transfers for treatment of large OLTs in an active duty US military population. Lesion morphology and magnetic resonance imaging (MRI) stage were recorded. Preoperative and latest postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot-ankle and pain visual analog scores were compared. Results. Eight male service members with mean age 34.4 years underwent structural allograft transfer for OLTs with mean MRI stage of 4.9 and a mean lesion volume of 2247.1 mm3. Preoperative mean AOFAS hindfoot-ankle score was 49.6, and mean pain visual analog score was 6.9. At mean follow-up of 28.5 months, postoperative mean AOFAS score was 73, and mean pain visual analog score was 4.5, representing overall improvements of 47% and 35%, respectively. Three patients were considered treatment failures secondary to continued ankle disability (2) or graft resorption requiring ankle arthrodesis. Conclusions. Despite modest improvements in short-term functional outcome scores, large osteochondral lesions requiring structural allograft transfer remain difficult to treat, particularly in high-demand patient populations. Surgeons should counsel patients preoperatively on realistic expectations for return to function following structural allograft transfer procedures.
Levels of Evidence: Level IV: Retrospective study
Ankle fractures are a common injury treated by orthopaedic surgeons. The distal tibiofibular syndesmosis can be injured during these fractures as well as in isolation. They pose a significant challenge with regard to the diagnosis of instability as well as evaluating reduction after fixation. Multiple studies have demonstrated that traditional radiographic analysis fails to accurately identify syndesmotic diastasis, instability, or malreduction. Ankle arthroscopy has been proposed as an alternative way to evaluate the syndesmosis. Ten transtibial amputation cadavers were utilized for this study. Two distinct analyses were undertaken. The first, analysis of instability, utilized 2 dissection groups, a superficial dissection only and a partial disruption instability model. The second analysis was of syndesmotic malreduction. For this, all 10 specimens underwent complete disruption of the syndesmosis and subsequent fixation in either anatomic alignment or malreduction. Both analyses were performed by surgeons blinded to the condition of the syndesmosis. Two groups of surgeons were able to identify syndesmotic instability a combined 75% of the time. Malreduction diagnosis was mixed with a 100% accurate diagnosis of sagittal plane displacement but only 50% accuracy for rotation and 17% for an anatomic reduction. Syndesmotic injury during ankle fracture presents a significant problem to the treating surgeon. Ankle arthroscopy has been shown in the literature to be highly sensitive for diagnosing instability but has not been evaluated in diagnosing malreduction. The current study shows moderate success in diagnosing both malreduction and instability.
Levels of Evidence: Therapeutic, Level V: Basic Science
This is a retrospective study (n = 39) evaluating the postoperative outcomes of patients with mild to moderate preoperative anemia who underwent a hindfoot and/or ankle arthrodesis. In the study, 32 patients did not have preoperative anemia, and 7 had preoperative anemia. Mortality, length of hospital stay, blood transfusions, deep-vein thrombosis, infection, time to union, malunion, delayed union, nonunion, and ulceration were of particular interest. Comparative analyses between patients with preoperative anemia and those without were performed utilizing the independent samples t-test or by the nonparametric Mann-Whitney U-test. The Fisher exact test was used to analyze categorical data. The Shapiro-Wilk test was utilized to check normality. Statistical significance was defined at a 2-sided level of P <.05. Delayed union, nonunion, and malunion were all significantly increased in patients with preoperative anemia (P = .032, P = .004, and P = .028, respectively). Accordingly, the median total number of noninfectious complications (delayed union + nonunion + malunion) in patients with preoperative anemia (0.86 ± 0.38) was significantly higher than in patients without preoperative anemia (0.063 ± 0.25; P < .001). Patients with preoperative anemia had a significantly longer length of hospital stay in days (4.14 ± 2.61). Total infection was also significantly associated with preoperative anemia (P = .001). This study clearly demonstrated that infectious complications, noninfectious complications, and length of hospital stay in hindfoot and/or ankle arthrodesis was significantly affected by preoperative anemia. Thus, consideration should be given to addressing preoperative anemia prior to hindfoot and/or ankle arthrodesis.
Levels of Evidence: Level II Study
Local anesthetic use for wound infusions, single injection, and continuous nerve blocks for postoperative analgesia is well established. No study has investigated the effect of a continuous block of the saphenous and superficial peroneal nerves at the level of the ankle joint following first ray surgery. A double blind randomized controlled trial was designed. One hundred patients with hallux valgus and rigidus requiring surgical correction were recruited and randomized to receive a postoperative continuous infusion at the ankle of normal saline or ropivacaine for 24 hours. Pain scores were recorded on postoperative days 1 and 7. There were more females than males. Follow-up was 100%. There were no significant differences in demographic data between the 2 randomized groups. There was no significant difference between the absolute visual analog scale scores on day 1 (P = .14) and day 7 (P = .16); nor was there a significant difference in reduction in scores between days 1 and 7 (P = .70). This study has shown no benefit to postoperative analgesia with the use of a continuous infusion of ropivacaine at the ankle. We, therefore, cannot currently recommend its use in the way described. Further studies may still identify a role for continuous local anesthetic infusions at the ankle to improve postoperative analgesia.
Levels of Evidence: Level I : Prospective randomised control trial.
In the literature, there have been several studies that have analyzed and explained the characteristics of physiological gait in association with pathologies; however, finding information about normal gait pattern while barefoot is difficult. This study focuses on the differences in the barefoot gait between children and adolescents. A total of 320 healthy children and adolescent were recruited and divided into groups according to age: G1 (1-6 years), G2 (7-10 years), G3 (>11 years). Data were collected using a dynamometric platform and analyzed using SPSS software. This study’s findings indicate that there are differences in the swing, stance, load, and single support phases of gait. To our knowledge, this is the first study to present the values of standardized data on barefoot gait pattern in children aged from 2 to 10 years.
Levels of Evidence: Diagnostic, Level IV: Case series
Introduction. Flexor hallucis longus (FHL) tendon transfer to the calcaneus is commonly used in the surgical treatment of chronic Achilles tendinopathy. This study assesses the integrity of FHL tendon biotenodesis screw fixation with respect to 2 variables: incorporation of a terminal whipstitch and tunnel depth. Materials and methods. A total of 60 fresh-frozen cadaver FHL tendons and 28 calcanei were harvested for analysis in 4 sets of fixation constructs; 14 whipstitched tendons were compared against their nonwhipstitched paired tendon via pull-out strength load testing, and 16 tendon pairs were randomized for fixation in either a full-depth tunnel (bicortical) or a 25-mm partial tunnel (unicortical). All comparisons were carried out in native bone and synthetic models. Results. Whipstitched tendons demonstrated significantly stronger mean clinical load (253.68 vs 177.24 N, P = .008) and maximum load to failure (294.31N vs 194.57 N, P = .001) compared with the nonwhipstitched tendons in synthetic bone. There were no statistical differences in mean clinical load (200.96 vs 228.31 N, P = .63) and maximum load to failure (192.69 vs 217.74 N, P = .73) between full and partial tunnel groups. There were no significant differences found in trials carried out in cadaveric bone. Conclusion. Use of a terminal whipstitch achieves greater fixation strength in FHL tendon biotenodesis transfers. Complete and partial tunnel constructs are equivocal in their pull-out strength. Data produced in a homogeneous bone substitute model demonstrate the biomechanical superiority of the whipstitch as well as the noninferiority of the partial tunnel technique.
Levels of Evidence: Level IIb
Background. The aim of the study is to create awareness in the practicing health care workers toward the problems encountered during casting and bracing of clubfoot following Ponseti method, and in turn avoid them. Material and Patients. Retrospective audit of 6 years’ clubfoot clinic records to analyze problems associated with Ponseti method. Observations. Problems were encountered in 26 cast and in 6 braced patients. Just 4 patients out of 71 syndromic (5.6%) experienced problems during casting compared with 3% overall incidence. The common problems encountered in casted patients were moisture lesions, hematoma, dermatitis due to occlusion, pressure sores, and fractures. There was excessive bleeding in 1 patient at time of tenotomy. In braced patients, pressure sores and tenderness at tenotomy site were major problems. None of the syndromic patients experienced difficulties during bracing. Conclusions. Problems were encountered with Ponseti method during casting, tenotomy, or bracing. Syndromic children had lesser complication rate than idiopathic clubfeet. It is important to be aware of these problems so that appropriate intervention can be done early.
Levels of Evidence: Level IV: Retrospective
Introduction. Ankle fractures are the third most common orthopaedic injury seen in the geriatric patient. Studies have identified mortality benefits with operative management, but treatment must be considered on a case-by-case basis. In the era of value-based analysis, a thorough of understanding of outcomes and costs of treatment is required. The purpose of this study was to analyze the inpatient and readmission costs associated with operative and nonoperative management of geriatric ankle fractures. Methods. Patients were identified using diagnosis codes for ankle fractures from all 2008 Part A Medicare claims. Patients younger than 65 years and those who sustained an ankle fracture during the previous year were excluded. Operative patients were then identified by ICD-9 procedure codes. Other variables collected included age, comorbidities, and the incidence of hospital readmissions. Inpatient costs were determined using Medicare reimbursement data. Results. A total of 19 648 patients with ankle fractures were identified. Of these, 15 193 (77.3%) underwent operative intervention. The mean cost for initial fracture admission was $5097.20 for nonoperative management compared with $8798.10 for operative management ( P < .05). The mean inpatient costs associated with readmission for nonoperative intervention was $5161.50 and for operative treatment, it was $5071.40 ( P > .05). The reimbursement for hospital readmissions for both groups combined for approximately $29.7 million. The total cost of initial treatment plus readmission for both treatment groups combined was approximately $185 million. Discussion. The total expenditure estimate of $185 million in this study has likely increased given the steady growth of the geriatric population. Expenditures associated with these readmissions was approximately $30 million—nearly a sixth of total costs. Future work must focus on determining which patients will benefit from operative intervention and optimizing care to decrease readmissions and their associated cost in this growing cohort of patients.
Levels of Evidence: Therapeutic, Level III: Retrospective study
Background. Ankle replacement surgery is an established and accepted way to treat end stage ankle arthritis. Though there are multiple publications looking at results with various ankle replacement systems, most of them are single implant longitudinal studies from a single institution. There are, however, no prospective randomized studies evaluating the outcomes of different total ankle arthroplasty (TAA) systems; in fact, there are no comparative studies at all. Methods. The comparative results of 3 different total ankle systems (INBONE, STAR, and Salto Talaris) were evaluated. All the TAA system implants were performed at a single institution from 2007 to 2011. The data were evaluated by authors completely independent from the study institution. The goal was to look at the results in an objective, noninstitution perspective. Results. At minimum 2-year follow-up there is no statistical difference in outcomes scores or functional tests between the INBONE, STAR, or Salto Talaris, with all 3 TAA systems resulting in statistically significant improvement of all parameters since baseline. Conclusions. This is the first study that compares the results of 3 different total ankle replacement systems done at a single institution over the same period of time. Even though it is not a randomized study, it gives a valuable perspective of the short-term results.
Levels of Evidence: Therapeutic, Level IV: Case series
Background. Impingement may be an underreported problem following modern total ankle replacements (TARs). The etiology of impingement is unclear and likely multifactorial. Because of the lack of conservative treatment options for symptomatic impingement after TAR, surgery is often necessary. Methods. We retrospectively identified a consecutive series of 1001 primary TARs performed between January 1998 and December 2014. We identified patients who required a secondary surgery to treat soft-tissue and bony impingement by either an open or arthroscopic procedure. Functional and clinical outcomes, including secondary procedures, infections, complications, and failure rates, were recorded. Results. In all, 75 patients (7.5%) required either open (n = 49) or arthroscopic debridement for impingement after TAR; 44 patients had >12 months of follow-up, with a follow-up of 26.5 months after their debridement procedure. The mean time to the debridement procedure for all prostheses was 29.3 months, with an average of 38.7 months in STAR, 21.8 months in INBONE, and 10.5 months in Salto Talaris patients. Of the patients with more than 1 year’s follow-up from their debridement, 84.1% were asymptomatic; 9 patients (20.4%) had repeat operations after their debridement procedure. Of these, 5 patients required a repeat debridement of their medial or lateral gutters for a failure rate of 11.4%. Conclusion. Both arthroscopic and open treatment of impingement after total ankle arthroplasty are safe and effective in improving function and pain. Although the rates for revision impingement surgery are higher in arthroscopic compared with open procedures, they are not significantly so. Therefore, we recommend arthroscopic surgery whenever possible because of earlier time to weight bearing and mobility.
Level of Evidence: Level IV
Intercuneiform instability has been recognized as a potential cause of hallux valgus recurrence following tarsal-metatarsal joint (TMTJ) fusion. Recommendations have been made for additional screw placement between the metatarsals and/or the cuneiforms to improve stability. The screw orientation that provides the best stability has not been documented. Twelve cadavers with the first TMTJ fixated were used for testing. Using a consistent force application of 15 pounds in both the transverse and coronal planes, we measured the change in intermetatarsal angle on radiographs. Force testing was repeated with screws deployed individually in the following orientations: first to second cuneiform (CC), first to second metatarsal (MM), and first metatarsal to middle cuneiform (MC). Our results indicate that stability of the first ray in the transverse and coronal planes is not improved with TMTJ fixation alone or with an additional CC screw. The MM screw consistently reduced first metatarsal instability in both planes. The MC screw had intermediate results. These findings strengthen the notion that first ray instability is complex and involves the tarsal and metatarsal articulations at multiple levels outside of the TMTJ alone.
Levels of Evidence: Diagnostic and Therapeutic, Level IV: Cadaveric Study
Soft tissue sarcomas of the foot and ankle are common. Currently, there exist limited data on prognostic variables. The aim of this study was to review our institution’s experience with soft tissue sarcomas of the foot and ankle to identify factors affecting outcomes and survivorship. We reviewed the records of 62 foot and ankle soft tissue sarcomas treated with definitive surgery at our institution between 1992 and 2013. The cohort consisted of 35 males and 27 females with a mean age at diagnosis of 45 years and a mean follow-up of 7 years. The most common tumor subtype was synovial sarcoma (n = 16). The overall limb salvage rate was 53%. Local recurrence was observed in 9 patients and distant metastases in 15 patients. Tumor size ≥3 cm in maximal dimension was the greatest risk factor in mortality. Posttreatment complications occurred in 15 patients. Local recurrence and development of distant disease was relatively common following wide excision of a soft tissue sarcoma of the foot and ankle. Tumors that were ≥3 cm in maximal dimension were associated with a worse overall survival and patients with neoadjuvant radiation were at increased risk of complications.
Levels of Evidence: Level IV: Retrospective Case Series
Total ankle replacement (TAR) is a viable alternative to ankle fusion in certain patients with end-stage ankle arthritis. Despite the importance of understanding alignment and movement of the prosthesis, there is no standardized radiographic method for evaluating the position and movement of the INBONE 2 prosthesis. The aims of this study were to describe a radiographic measurement protocol for INBONE 2 for clinical practice and research while determining the interobserver and intraobserver reliability using standard weightbearing radiographs. Fifteen patients were randomly selected with operative dates from January 2011 to January 2014 who underwent primary TAR using the INBONE 2 prosthesis. Most recent preoperative and first postoperative weightbearing anteroposterior and lateral radiographs were pulled and deidentified. Three foot and ankle surgeons blinded from the patient selection and deidentification, measured the described measurements on separate occasions. Intraobserver reliability: surgeon 1 had acceptable reliability for 9 of 13 continuous radiographic measurements (69.2%), surgeon 2 had acceptable reliability for 8 of 13 measurements (61.5%), and surgeon 3 had acceptable reliability for 12 of 13 measurements (92.3%). Interobserver reliability: among the first measurements, 6 of 13 continuous radiographic measurements (46.2%) had acceptable reliability. Among the second measurements, 7 of 13 measurements (53.8%) had acceptable reliability. Among the first and second measurements combined, 7 of 13 measurements (53.8%) had acceptable reliability. This study promotes the need for meticulous evaluation of annual radiographic findings following TAR in an effort to avoid catastrophic failure and represents moderate agreement can be obtained by employing the proposed measurements for surveillance of INBONE 2 TAR at annual postoperative visits. Measurements on the anteroposterior radiograph appear to demonstrate more consistent results for surveillance than lateral measurements. The intraobserver reliability results were somewhat superior to the interobserver reliability, implying more relevance for a single surgeon applying these measurements annually for postoperative surveillance.
Levels of Evidence: Diagnostic, Level III
Background. Tibiotalocalcaneal arthrodesis is a salvage procedure for patients with complex disease of the ankle and subtalar joints. Despite the clinical efficacy and mechanical advantage of intramedullary nails, complications, such as nonunion, are common. It may be possible to sustain compression in the face of bone resorption and implant loosening over the course of healing using a novel pseudoelastic intramedullary nail with an internal nitinol element. Methods. We identified 15 patients with average age of 54.7 years (range, 28-75 years) who had undergone a tibiotalocalcaneal arthrodesis using a pseudoelastic intramedullary nail. Serial radiographs were used to determine the amount and rate of nitinol element migration over the first 3 postoperative months. Results. Postoperatively, there was at least 2.38 mm of nitinol element migration proximally with mean of 5.58 mm (± 1.38), (range, 2.38-8.11 mm). Average follow-up time was 195 days (± 106.3), (range, 89-490 days). On average, 86% of the total recovered distance took place within the first 39.7 days (±10.03). Conclusions. The nitinol element recovers distance when stretched intraoperatively and maintains moderate compression in response to bone resorption. Further studies are needed to assess if this increased compression lends itself to higher fusion rates than traditional intramedullary nails.
Levels of Evidence: Therapeutic, Level IV: Case series
Current literature is inconsistent concerning the causes and the frequency of idiopathic toe walking (ITW). Available studies vary widely in their results. The aim of this study is to supply gender-related data particularly regarding the genetic influence on toe walking. Methods. The ITW patterns of 836 children were recorded and analyzed during a period of 4 years. Questionnaires and clinical measurements were evaluated along with clinical tests, assessing the occurrence and severity of toe walking. Information about the incidence of toe-walkers in the family was recorded. Results. Of the 836 toe-walkers, 64% were boys and 42% had a positive family history (PF-TW). About 60% of the PF-TW children had fathers with a positive toe-walking pattern. PF-TW children were on average half a year younger than children with a negative family predisposition (NF-TW). Conclusions. This study shows that a genetic component might be factor in toe walking. PF-TW children were more severely affected in all performed clinical tests than NF-TW children.
Levels of Evidence: Prognostic, Level IV
Subtalar joint distraction arthrodesis has been well reported with use of structural iliac crest or local autologous bone graft for malunited calcaneal fractures. Early reports for structural allograft did not yield good, consistent results, leading to a subsequent lack of recommendation in previous literature. Newer studies have had promising results utilizing femoral allograft as an alternative to autogenous bone graft. We performed a retrospective chart review on 10 patients (12 feet) undergoing subtalar joint distraction arthrodesis with femoral neck allograft for malunited calcaneal fractures. The primary aim of this study was to report on successful union rates and, in addition, outline any consistent complications. Twelve of the 12 procedures (100%) yielded successful fusion with a mean final follow-up of 7.7 months (range = 2.2-35.1 months). The mean increase in talocalcaneal height was 4 mm (range = 2-6 mm). The overall complication rate was 16.6%, including one superficial wound complication that healed uneventfully and one hardware removal. In conclusion, the current study reports a 100% successful fusion rate with interpositional structural femoral neck allograft in treatment for malunited calcaneal fractures.
Levels of Evidence: Therapeutic, Level IV: Case series
Background. Bohler’s angle (BA) is the most commonly utilized radiographic measurement in the study of calcaneus fractures and has been shown to be prognostic in nature. Therefore, it is critical that the measurement of BA be accurate as both therapeutic and prognostic information relies on it. Oblique lateral radiographs can be a cause of error in BA measurements. However, measurement error and the effects of X-ray beam obliquity on BA have not been established in the literature. The purpose of this study was to determine measurement error and understand the effects of X-ray beam’s obliquity on the measurement of BA. Methods. A cadaver specimen was imaged using a C-arm to obtain a perfect lateral radiograph of the ankle and slightly oblique lateral views in the anterior, posterior, cephalad, and caudad directions in 5° increments (21 images). Metallic beads were then placed on the anterior calcaneal process, posterior facet, and the superior aspect of the posterior tuberosity, and the same 21 images were then obtained. The metallic beads placed on the reference radiographs allowed the authors to accurately measure BA for each image and served as reference for the corresponding test radiographs. Thirty-four orthopaedic staff members participated in the study and used DICOM measurement tool to measure BA on each of the 21 test radiographs. The measurements were then compared to the measurements of BA from the reference radiographs to determine error in measurement. Results. A total of 714 different measurements were obtained. Average measurement error was 6° (95% confidence interval = –4° to 15°). The difference between the observed BA measurements compared to the true BA measurements increased with increasing X-ray obliquity. Conclusions. Measurement error for BA is ±6° and increases most with cephalad oblique radiographs. Orthopaedic surgeons’ ability to accurately measure BA significantly decreases with increasing obliquity of the lateral radiograph.
Levels of Evidence: Level V: Cadaver bench study
Background. Nonunion of an ankle arthrodesis is associated with significant pain and morbidity. Revision arthrodesis presents greater short-term morbidity and long-term sequelae. 1-6 Recent reports have demonstrated the feasibility of converting a symptomatic nonunion of an ankle arthrodesis to a total ankle arthroplasty.7-9 The objective of the present study was to evaluate the short-term outcome associated with take down of symptomatic nonunions of ankle arthrodeses and conversion to a fixed bearing, intramedullary total ankle arthroplasty. Methods. Five patients with symptomatic, aseptic tibiotalar arthrodesis nonunions (average age, 62.2 years), who underwent conversion to a total ankle arthroplasty were retrospectively identified and assessed at a prospective office visit. Minimum follow-up was 12 months (average, 21.3 months). Clinical outcomes were assessed on the basis of the American Foot and Ankle Society (AOFAS) ankle-hindfoot score10 and the Foot Function Index.11,12 Radiographic analysis, patient satisfaction and pain levels were also evaluated. Results. The average post-operative AOFAS ankle-hindfoot score was 82.6, while the FFI was 28.2%. The average clinical range of motion was 35 degrees. Visual analog scale (VAS) pain scores averaged 31.1 out of 100. Four out of the five patients were very satisfied or satisfied. Radiographically, the tibial and talar components were stable in all patients without evidence of loosening, migration, or subsidence. There were no complications requiring additional procedures. Conclusions. Patients undergoing ankle arthrodesis that is complicated by an aseptic nonunion pose a difficult clinical problem. Conversion to a total ankle arthroplasty with a fixed bearing, intramedullary implant is a viable treatment option with reliable short-term results.
Levels of Evidence: Therapeutic, Level IV: Case series
Lower-limb immobilization has been implicated as an etiological factor for venous thromboembolic events (VTEs). However, there is no patient-centered scoring system available for risk assessment in ambulatory trauma patients with temporary lower-limb immobilization. A patient questionnaire scoring system has been developed for ambulatory patients with foot and ankle fracture being managed nonoperatively as outpatients by temporary lower-limb immobilization. Patients are classed as either high or low risk for developing a VTE and offered low-molecular-weight heparin (LMWH) accordingly. This is a prospective study of 150 patients with a follow-up of 6 months. Only 3 patients developed VTEs: one was noncompliant with medicine, one was started on LMWH 2 days after getting a plaster cast, and the third was not started on LMWH in spite of family history of VTEs. This study showed that using this scoring system, LMWH can be used safely and effectively as a thromboprophylactic agent for ambulatory trauma patients requiring temporary lower-limb immobilization to manage foot and ankle fractures. It is a step toward developing a validated clinical prediction score to enable risk assessment in ambulatory trauma patients who are managed non-operatively with temporary lower limb immobilization.
Levels of Evidence: Prognostic, Level IV: Case series
Objective. This study was conducted to determine the most effective thermal modality; heat or contrast therapy—in reducing pain, reducing swelling, and increasing range of movement (ROM) of the grade I and II lateral ankle sprain in the prechronic stage of the subacute phase. Design. Randomized control trail. Methods. One hundred and fifteen participants of both genders who were diagnosed as having grade I or II lateral ankle sprain were randomly assigned to the study on the fifth day of injury. Pain, volume, and ROM were recorded before and after treatment continuously for 3 days. Results. Effects were evaluated as "Immediately after application" and "3 days after continuous application." Immediately after application, there was no difference between the 2 modalities on ankle ROM; heat reduced pain over contrast therapy, and both modalities increased swelling. When considering the effects after continuous application for 3 days, no difference was found between the 2 modalities on ROM and the reduction of pain. Contrast therapy reduced swelling while heat caused increased swelling even after 3 days. Conclusion. The use of different thermal modalities during the transition from the acute to chronic phase of injury can be suggested as effective treatment options according to the objectives of injury management: pain reduction, improve ROM, and swelling management.
Levels of Evidence: Therapeutic, Level II: Randomized clinical trial
Purpose. Steenbeek foot abduction brace (SFAB) has been widely used in various national clubfoot programs. The aim of the study was to define effectiveness and dynamicity of SFAB in terms of dorsiflexion and pronation for the corrected clubfoot. Methods. Differences in foot dorsiflexion and pronation measurement with brace in knee flexed and extended position were recorded as dynamicity1 and dynamicity2, respectively. The residual soft tissue stretch lag despite brace use was calculated by determining the difference between maximum foot dorsiflexion (stretchlag1) and pronation (stretchlag2) achievable without and with brace in knee flexed. Statistical difference between measurements were calculated using paired t tests. Results. There were a total of 63 feet in 40 patients. The mean foot dorsiflexion with brace on in knee extension was 7.57° and in flexion was 15.20°. The foot pronation with brace on in knee extension was 9.46° and in flexion was 16.77°. Thus, SFAB exerted statistically significant differences in foot dorsiflexion and pronation between the knee extended and flexed positions. Dynamicity1 and dynamicity2 were 7.63° and 7.31°, respectively. Stretchlag1 was 18.47° and stretchlag2 was 17.63°. Conclusions. SFAB demonstrates effective dynamicity in maintaining corrected foot dorsiflexion and pronation. There is a residual soft tissue stretch lag both in dorsiflexion and pronation in corrected clubfoot despite use of SFAB.
Levels of Evidence: Therapeutic, Level IV: Case series
Background. The typical bunionette deformity often presents as pain over the lateral margin of the fifth metatarsal head. There have been numerous operative treatments described for this pathology. The purpose of this study was to evaluate the results after a reverse Ludloff osteotomy in cases of severe bunionette deformities. Methods. Between 2008 and 2012, 16 patients received a reverse Ludloff osteotomy of the fifth metatarsal due to a symptomatic type II or III bunionette that failed nonoperative treatment. We retrospectively reviewed charts, radiographic images, postoperative AOFAS (American Orthopaedic Foot and Ankle Society) lesser toe scores, and the EQ-5D at a mean of 41.9 months (range, 31-74 months) of follow-up. Additionally, limitation in activities of daily living, pain, and patient satisfaction were assessed. Results. At latest follow-up, the mean AOFAS lesser toe score was 86.6 points and the mean EQ-5D score was 14.1. Fifteen patients had no or only little limitations. Fifteen out of 16 patients were satisfied or predominantly satisfied. Radiographic analysis showed for type II deformities a correction of the lateral bowing from 8.1° down to 0.67° (P < .001). The fourth-fifth intermetatarsal angle (4-5 IMA) improved from a mean of 13.2° to a mean of 5.2° (P < .001). The length of the fifth metatarsal was unchanged (P > .05). There were no observed complications, and no revision was necessary. Conclusion. In the present study, the reverse Ludloff osteotomy had a high satisfaction rate and no complications. It provided radiographic correction of the deformity and may be considered in the surgical treatment of severe bunionette deformities.
Levels of evidence: Therapeutic, Level IV: Case series
The aim of this study was to evaluate survivorship and risk factors for failure of total ankle arthroplasty (TAA) in the United States using large statewide, multipayer databases of inpatient discharges. TAA patients from 2005 to 2009 were identified from the Healthcare Cost and Utilization Project databases for 5 states (California, Florida, Nebraska, North Carolina, and Utah) and the New York Department of Health Statewide Planning and Research Cooperative System database. Patient demographics and clinical characteristics were extracted, and a multivariable logistic regression model was developed to assess risk factors for 90-day all-cause readmission and failure. Failure was defined as revision, arthrodesis, amputation, or implant removal. During the period of interest, 1545 patients received 1593 TAA. The coded etiology of arthritis was primary osteoarthritis (n = 854, 55.2%), posttraumatic arthritis (n = 466, 30.2%), rheumatoid arthritis (n = 129, 8.4%), and other (n = 96, 6.2%). The 5-year survival rate was 90.1%. Patients with a coded diagnosis of rheumatoid arthritis (odds ratio [OR] = 2.18; 95% confidence interval [CI] = 1.04-4.01) or who were readmitted within 90 days of TAA (OR = 3.41; 95% CI = 1.67-6.97) had significantly increased risk of failure. Risk factors for readmission were Charlson-Deyo Score ≥2 (OR = 3.05; 95% CI = 1.51-6.15) and increased length of stay during the arthroplasty (OR = 1.30; 95% CI = 1.16-1.47).
Levels of Evidence: Therapeutic, Level IV: Observational study
Background. When Achilles tendon ruptures become chronic, a defect often forms at the rupture site. There is scant literature regarding the treatment of chronic Achilles ruptures with defects of 6 cm or larger. We examined outcomes from combining a turndown of the proximal, central Achilles with a flexor hallucis longus (FHL) tendon transfer to treat this condition. Materials. Between September 2002 and December 2013, 32 patients presented with a chronic Achilles rupture and a defect of 6 cm or more. Twenty patients were male and 12 were female. Patient age was between 20 and 74 years, with a mean of 53.3 years. Eighteen and 14 patients had their right and left Achilles tendon affected, respectively. The number of days between injury and surgery ranged from 30 to 315 days, with a mean of 102 days. Reconstruction of the Achilles involved a turndown of the proximal, central tendon and FHL augmentation. Final patient follow-up ranged from 18 to 150 months, with a mean of 62.3 months. Results: At surgery, the gap between the ruptured ends of the Achilles ranged from 6 to 12 cm, with a mean gap of 7.5 cm. Full healing was achieved in all 32 patients (100%) by 5 months postoperatively. Mean Foot and Ankle Ability Measures scores increased from 36.3% to 90.2% between initial and latest follow-up (P < .05). Mean visual analogue scales of pain decreased from 6.6 to 1.8 of 10 between first and last encounter (P < .05). Postoperative complications occurred in 5 patients (15.6%), including 3 (9.4%) superficial wound problems, 1 (3.1%) deep wound infection, and 1 (3.1%) deep vein thrombosis. Discussion. Outcomes from treating chronic Achilles ruptures with large defects are scant within the orthopaedic literature. Our method of Achilles reconstruction results in a high rate of improved function and pain relief.
Levels of Evidence: Therapeutic, Level IV: Case series
The aim of this study is to provide clinical examination methods that were designed specifically to assess the level of severity among children with idiopathic toe walking (ITW). The idiopathic toe-walking pattern of 836 children was recorded and analyzed during 4 years. Questionnaires and clinical measurements were evaluated, along with differential tests, assessing the occurrence and severity of toe walking. Questions about family history and onset of toe walking were evaluated along with special tests and measurements assessing the occurrence and severity of toe walking. The different measurements apply during this study, ankle dorsiflexion, lumbar lordosis angle, as well as the clinical spin test, walking after spin test, and heel walking test revealed in all cases that children with a positive family predisposition were significantly more affected than children with negative family predisposition. It is concluded that children with ITW and a positive family predisposition were more intensively affected during all performed clinical tests than children with no family predisposition. The tests used during this study have not being used by any other researches, even though they showed significant differences between the children with ITW and children with a normal gait pattern.
Levels of Evidence: Diagnostic, Level II: development of diagnostic test with consecutive patients and control patients
Background. The optimal fixation method for the first tarsometatarsal arthrodesis remains controversial. This study aimed to develop a reproducible first tarsometatarsal testing model to evaluate the biomechanical performance of different reconstruction techniques. Methods. Crossed screws or a claw plate were compared with a single or double shape memory alloy staple configuration in 20 Sawbones models. Constructs were mechanically tested in 4-point bending to 1, 2, and 3 mm of plantar displacement. The joint contact force and area were measured at time zero, and following 1 and 2 mm of bending. Peak load, stiffness, and plantar gapping were determined. Results. Both staple configurations induced a significantly greater contact force and area across the arthrodesis than the crossed screw and claw plate constructs at all measurements. The staple constructs completely recovered their plantar gapping following each test. The claw plate generated the least contact force and area at the joint interface and had significantly greater plantar gapping than all other constructs. The crossed screw constructs were significantly stiffer and had significantly less plantar gapping than the other constructs, but this gapping was not recoverable. Conclusions. Crossed screw fixation provides a rigid arthrodesis with limited compression and contact footprint across the joint. Shape memory alloy staples afford dynamic fixation with sustained compression across the arthrodesis. A rigid polyurethane foam model provides an anatomically relevant comparison for evaluating the interface between different fixation techniques. Clinical Relevance. The dynamic nature of shape memory alloy staples offers the potential to permit early weight bearing and could be a useful adjunctive device to impart compression across an arthrodesis of the first tarsometatarsal joint.
Level of Evidence: Therapeutic, Level V: Bench testing
Wound dehiscence and infection may arise when the skin around the foot or ankle is closed under tension after a surgical incision or trauma. Two cases where a piecrusting technique, using small transdermal incisions made in the surrounding skin similar to the holes in a pie crust, are presented and a literature review of the technique has been performed. The multiple small stab incisions perpendicular to the line of tension have enabled skin closure without tension and have healed with minimal scarring.
Levels of Evidence: Level V: Expert opinion
Talonavicular (TN) arthrodeses for TN arthritis have a high rate of nonunions for an essential hindfoot joint. In this case series, 12 patients underwent an isolated TN arthrodesis using a novel implant (IO FiX) by a single surgeon with a minimum 1-year follow-up (30.1 ± 14.7 months; mean ± SD). All patients (62 ± 12 years) underwent an aggressive rehabilitation protocol given the strength and compression of the implant. There were no nonunions, nor were there any patients lost to follow-up. Time to radiographic union was 9.6 ± 1.4 weeks. The Visual Analog Scale pain level decreased from 7.3 ± 0.9 preoperatively to 2.1 ± 0.7 postoperatively (P < .001). The Short-Form-12 physical component improved from 27.9 ± 4.2 preoperatively to 42.2 ± 3.5 postoperatively (P < 0.001), while the Short-Form-12 mental component did not change from 50.8 ± 6.9 preoperatively to 54.4 ± 3.8 postoperatively (P > .05). Use of the novel fixation device for TN arthrodesis by a single surgeon with an accelerated rehabilitation protocol significantly decreased patients’ pain and improved their physical functional outcomes (P < .001). The IO FiX implant can potentially improve TN arthrodesis fusion rates and surgical outcomes.
Levels of Evidence: Therapeutic, Level IV: Case series
During a cheerleading event, a 14-year-old female sustained a right ankle physeal fracture that was treated nonoperatively with casting. She developed a distal medial tibial physeal arrest, and as the onset of menses was at age 16, she subsequently developed a varus distal tibial deformity. At the age of 19, she was no longer able to participate in collegiate cheerleading due to lateral ankle pain, ankle instability, and peroneal subluxation. After failing conservative treatment, she underwent an ankle arthroscopy, Broström-Gould procedure, peroneal retinacular repair with peroneal tenolysis, and a distal tibial medial opening wedge osteotomy using a porous titanium metal wedge and a one-third tubular plate. At 6-month follow-up, her osteotomy site showed abundant callus formation, and her lateral ankle pain had almost completely resolved. At 22-month follow-up, there were no residual ankle instability or pain complaints, and she had returned to collegiate cheerleading. This case report highlights a very useful, previously not described, application of porous titanium metal wedges for medial supramalleolar opening wedge osteotomies of the tibia. Such wedges are familiar to many foot and ankle orthopaedic surgeons and continue to have expanding indications.
Levels of Evidence: Therapeutic, Level IV: Case report
Bone marrow edema syndrome (BMES) is a condition characterized by pain and an increase interstitial fluid within the bone marrow in the absence of a definable cause. The purpose of this study was to assess the changes in the pattern of bone edema and quality of pain over time. In patients diagnosed with BMES of the foot and ankle, we investigated the benefit of treatment with bisphosphonates and immobilization in a pneumatic walking boot compared with immobilization in a boot alone. This study is a retrospective review of 18 consecutive patients (mean age 54 years) diagnosed with foot and ankle BMES. Twelve (67%) patients were female and 6 were male with a mean age of 60.1 and 43.0 years, respectively (P < .05). The minimum follow-up was 2 years (range 2-11 years, mean 5.75 years). Five females and no males were found to suffer from generalized osteoporosis. The average duration of symptoms prior to presentation was 22 weeks and the most common bone affected was the talus (56%). More than one bone was affected in 8 (44%) patients. All patients were given a walking boot at first attendance for 8 weeks. The mean time to resolution of pain in patients treated with a pneumatic walker alone (7 patients) was 25.6 weeks (range 8-36 weeks). In the 11 patients whose pain had not improved at their first follow-up, treatment with bisphosphonates led to a more rapid resolution of pain in 13.8 weeks if given intravenously, and 24.0 weeks if given orally. Statistical analysis demonstrated a significant advantage in using a bisphosphonate versus a protected weightbearing alone (P < .01). Recurrence within the same foot and ankle occurred in 44% of patients at a mean interval of 15.6 months and migration to a different site occurred in 6% of patients.
Levels of Evidence: Therapeutic, Level III: Retrospective, comparative trial
Bone marrow aspiration (BMA) is a validated technique to harvest progenitor cells. BMA has many uses in foot and ankle surgery; however, donor site morbidity is a concern. The purpose of this study was to compare the Visual Analog Scale (VAS) pain scores after BMA at 3 different sites (iliac crest, distal tibia, and calcaneus) over a 12-week postoperative recovery period. This was an institutional review board–approved prospective study of 40 patients who underwent BMA as an adjunct to their primary foot and ankle procedure. Each patient had BMA harvested from the ipsilateral anterior iliac crest, distal tibia, and lateral calcaneus at the time of surgery. Patient follow-up questionnaire forms were filled out at 2, 4, 8, and 12 weeks, with the primary outcome measure being VAS pain scores. Mean VAS scores averaged over the 12-week follow-up period were significantly higher in the calcaneus (20.8 ± 28.6) compared with the distal tibia (7.7 ± 17.6) and the iliac crest (4.2 ± 12.4; P < .05). No significant difference was found between the distal tibia and the iliac crest sites. At 12 weeks, all sites were about equal and without appreciable pain. Our data suggested that donor site selection for BMA affects postoperative pain levels, with BMA from the calcaneus resulting in significantly higher pain scores when compared with the iliac crest or distal tibia. The VAS pain score for the calcaneus was likely confounded by the high number of hindfoot/ankle surgeries performed in the ipsilateral foot.
Levels of Evidence: Therapeutic, Level II: Prospective, comparative trial
Objective. The objective of the present study is to utilize a national database to examine the association between obesity and postoperative complications after primary Achilles tendon repair. Methods. The PearlDiver database was queried for patients undergoing primary Achilles repair using CPT 27650. Excision of a Haglund’s deformity or tendon transfer were exclusion criteria. Patients were then divided into obese (body mass index [BMI] > 30 kg/m2) and nonobese (BMI < 30 kg/m2) cohorts using ICD-9 codes. Complications within 90 days postoperatively were assessed using ICD-9 and CPT codes. Results. In all, 18 948 patients who underwent primary Achilles tendon repair were identified from 2005 to 2012. Overall, 2962 patients (15.6%) were coded as obese or morbidly obese. Obese patients had significantly higher rates of postoperative wound complications (odds ratio [OR] = 2.1; P < .0001), infection (OR = 1.8; P < .0001), venous thromboembolism (VTE; OR = 1.8; P = .001), and medical complications (OR = 3.9; P < .0001) compared with nonobese patients after primary Achilles tendon repair. Additionally, obese patients had a significantly lower rate of ankle stiffnesassociated with a significantly higher risk of s (OR = 0.4; P < .0001) compared with nonobese patients. Conclusion. Obesity is associated with a significantly higher risk of wound complications, infection, VTE, and medical complications after primary Achilles tendon repair.
Levels of Evidence: Prognostic, Level II: Retrospective study
Background: The Weil oblique distal metatarsal osteotomy is regularly used in the treatment of primary metatarsalgia. The most frequent complication is the floating toe, which occurs in up to 36% of postoperative follow-up. The theory of reducing the plantar flexor mechanism tension associated with the retraction of the dorsal structures during the healing process of the surgical procedure may explain this negative evolution. Objective: This study aimed at assessing the effectiveness of the Tucade dorsal thermoplastic locking orthosis in the prevention of floating toe after Weil osteotomy. Methods: In all, 30 patients with metatarsalgia diagnosis submitted to Weil osteotomy were treated in the postoperative period with the Tucade dorsal thermoplastic locking orthosis. Results: The floating toe was not observed in this case series. There was 1 case of superficial wound irritation at the dorsal surgical incision and 1 case that evolved with transfer metatarsalgia. Statistical analyses were performed—American Orthopaedic Foot and Ankle Society Scale for lateral toes and extension of the lateral toes—using the t test, and P < .0001 was obtained for comparison of the preoperative and postoperative periods in the population studied. Conclusion: The Tucade dorsal thermoplastic locking orthosis during the postoperative period of Weil osteotomy proved to be effective in the prevention of floating toes.
Level of Evidence: Therapeutic Level IV: Case Series
Cystic talar shoulder defects are particularly challenging osteochondral lesions. A retrospective chart review was performed on 13 adults that previously failed microfracture, presented with medial cystic osteochondral lesions of the talus, and were treated with malleolar osteotomy and subchondral allograft reconstruction. The aim of the study was to evaluate the effect of a medial malleolar osteotomy and allograft subchondral bone plug on pain and function. We hypothesized that following surgery, pain and function would significantly improve. Compared with preoperative measures, pain (first step in the morning, during walking, at the end of the day) and function (descending the stairs, ascending the stairs, and ambulating up to 4 blocks) improved postoperatively at 6 and 12 months (P ≤ .001). During each activity, pain improved postoperatively from 6 to 12 months (P ≤ .006). Postoperatively, from 6 to 12 months, the level of disability improved while descending the stairs (P = .004), and the level of disability experienced while ascending the stairs and ambulating up to 4 blocks was maintained (P ≥ .02). Multiple regression analyses identified body mass index as a predictor of preoperative function (R2 = .34, P = .04). No variables were identified as significant predictors of postoperative pain or function. With all osteotomies healing, no graft rejection, and a single deep venous thrombosis, allograft subchondral plugs appear to successfully treat osteochondral lesions of the talus with improvements in pain and function as well as an acceptable complication rate.
Level of Evidence: Therapeutic, Level IV: Retrospective Case Series.
The purpose of this study was to evaluate a series of patients undergoing a single platelet-rich plasma (PRP) injection for the treatment of chronic midsubstance Achilles tendinopathy, in whom conservative treatment had failed. Thirty-two patients underwent a single PRP injection for the treatment of chronic midsubstance Achilles tendinopathy and were evaluated at a 6-month final follow-up using the Foot and Ankle Outcome Score and Short Form 12 general health questionnaire. Magnetic resonance imaging was performed on all patients prior to and 6 months after injection. Twenty-five of 32 patients (78%) reported that they were asymptomatic at the 6-month follow-up visit and were able to participate in their respective sports and daily activities. The remaining 7 patients (22%) who reported symptoms that did not improve after 6 months ultimately required surgery. Four patients went on to have an Achilles tendoscopy, while the other 3 had an open debridement via a tendon splitting approach. A retrospective evaluation of patients receiving a single PRP injection for chronic midsubstance Achilles tendinopathy revealed that 78% had experienced clinical improvement and had avoided surgical intervention at 6-month follow-up.
Levels of Evidence: Therapeutic, Level IV: Retrospective case series
In literature, one finds little scientific statements regarding plantar static pressure distribution in healthy individuals. Miscellaneous studies, however, characterize pathologies of feet and associate those with abnormal static or dynamic plantar load sharing. Our study reveals that healthy individuals show significant age-dependent differences in forefoot and rear foot load measured in standing position. The forefoot and rear foot load of 238 female and 193 male individuals aged between 2 and 69 years were measured. Using a pressure distribution measurement platform, the measurements were taken barefooted in standing position. Those measurements are presented as percentage of the overall load. The measurements within the age groups A1 (2-6 years), A2 (7-10 years), and A3 (11-69 years) showed significantly different forefoot loading means of the left foot (A1, 19.9%; A2, 28.2%; A3, 39.7%) and the right foot (A1, 22.6%; A2, 29.7%; A3, 39.6%). The forefoot loadings are graphically displayed as a function of the percentiles 5, 10, 25, 50, 75, 90, and 95. Forefoot loadings are referred to as "prominent" if the measured values lie off the interquartile range; if either below the percentile 10 or above 90 the loadings are referred to as "very prominent." Our study contains significant data regarding the extent of the static load sharing of the forefoot and rear foot of healthy individuals; the data are suited for being standard values to evaluate plantar load sharing.
Levels of Evidence: Diagnostic Level IV: Case series
Introduction: Avascular necrosis (AVN) of the talus is a challenging entity to treat. Poor outcomes remain all too common. The purpose of this systematic review was to: identify and summarize all available evidence for the treatment of talar AVN; provide treatment recommendations; and highlight gaps in the literature. Methods: We searched MEDLINE and EMBASE using a unique algorithm. The Oxford Level of Evidence Guidelines and GRADE recommendations were used to rate the quality of evidence and to make treatment recommendations. Results: 19 studies fit the inclusion criteria constituting 321 ankles at final follow-up. The interventions of interest included hindfoot fusion, conservative measures, bone grafting, vascularized bone graft, core decompression, and talar replacement. All studies were Level IV evidence. Due to study quality, imprecise and sparse data, and potential for reporting bias, the quality of evidence is "very low". Studies investigating conservative therapy showed that prolonged protective weight bearing provides the best outcomes in early talar AVN. Discussion: Given the "very low" GRADE recommendation, understanding of talar AVN would be significantly altered by higher quality studies. Early talar AVN seems best treated with protected weightbearing and possibly in combination with ESWT. If that fails, core decompression may be an attractive treatment option. Arthrodesis should be saved as a salvage procedure. Future prospective, randomized studies are necessary to guide the conservative and surgical management of talar AVN.
Level of Evidence: Level II
The calcaneonavicular (spring) ligament complex is a critical static support of the medial arch of the foot. Compromise of this structure has been implicated as a primary causative factor of talar derotation leading to the clinical deformity of peritalar subluxation. Few procedures have been described to address this deficiency. The technique we describe here is a simple yet effective method to reconstruct the spring ligament complex that can easily be used in conjunction with other more commonly used procedures for extra-articular reconstructions of this deformity. We believe this procedure allows for a more powerful deformity correction and may decrease dependency on other nonanatomic reconstructive procedures.
Diabetes is the leading cause of nontraumatic amputations. Although laboratory assessment may not alone determine the optimal level of amputation thorough assessment of a variety of laboratory values is critical to overall care of the patient and may place the patient into risk category. This systematic review analyzes publications related to diabetic lower extremity amputations and associated laboratory values, including lymphocyte count, albumin, hemoglobin, and glycemic control.
Levels of Evidence: Diagnostic, Level IV
Background. Foot and ankle surgeons are in a unique position to educate patients about the importance of proper footwear. Neither their recommendations regarding shoe selection nor their own footwear patterns have previously been reported. Methods. A total of 866 members of the American Orthopaedic Foot & Ankle Society (AOFAS) were asked to complete a survey via the Internet. Topics included specific shoe brands recommended to patients, how attributes of footwear are communicated, and respondents’ footwear habits. Results. In all, 276 (32%) surgeons responded, and 64% recommended New Balance athletic shoes to patients; 26% did not recommend specific brands. It was found that 50% wear New Balance athletic shoes; 25% wear Nike. Rockport (27%) and SAS (27%) were the most recommended dress shoes. In all, 76% are familiar with AOFAS guidelines for proper shoe fit, but only 56% educated their patients about the guidelines; 43% do not consider what patients might think of their shoes when selecting what to wear in the clinical setting. Conclusions. Despite the multitude of different brands, several were commonly recommended. Respondents seem to be aware of the impact of their own shoe selection on patients’ perspectives of footwear, but many do not consider themselves role models for proper footwear.
Level of Evidence: Internet survey
Ankle fractures patterns in children may vary depending on the maturity of the distal tibial and fibular physis. Bimalleolar ankle fracture is an exceedingly rare fracture pattern in children and has been reported once in the current English literature. Two further adolescents with bimalleolar ankle fracture are reported. Although these fractures are rare, surgeons should be aware of these atypical fracture patterns. Herein, the underlying physiology and the mechanism of injury of ankle fractures in children are discussed.
Level of Evidence: Therapeutic, Level IV, Case study
The aim of the present study was to evaluate balance deficits after an ankle sprain in collegiate students and to examine the effectiveness of 2 different balance rehabilitation programs on balance ability. Thirty collegiate students with functional ankle instability were randomly divided into 2 groups. Both groups followed an intervention balance program for 6 weeks, 3 times per week, 20 minutes per session, using balance boards. One of the 2 training groups performed the exercises on the ground—the "Land" group (
Level of Evidence: Therapeutic, Level 1