Arthrodesis of the subtalar and talonavicular joints for correction of symptomatic hindfoot malalignment.

BACKGROUND: Triple arthrodesis has long been used for the treatment of painful malalignment or arthritis of the hindfoot. However, the effect of fusion on adjacent joints has sparked interest in a more limited arthrodesis in patients without involvement of the calcaneocuboid joint. METHOD: Results of 16 feet in 14 patients who had a modified double arthrodesis for symptomatic flatfoot, cavovarus deformity, or hindfoot arthritis were reviewed retrospectively with a minimum followup of 18 (range 18 to 93) months. The most common diagnosis contributing to the hindfoot deformity was pes planovalgus. All operations were done with a consistent technique using rigid internal fixation with screws. In 15 feet, a concomitant gastrocnemius recession for equinus contracture was done at the time of the primary surgery. Clinical evaluation was based on the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale in addition to subjective assessments of pain, function, shoewear, cosmesis, and overall satisfaction. Radiographic evaluation included measurements of the anterior-posterior talo-second metatarsal angle, lateral talocalcaneal angle, and lateral talo-first metatarsal angle, and notation of arthritic changes of the ankle, calcaneocuboid, and midfoot joints, as well as an assessment of time to union of all arthrodeses. RESULTS: The average AOFAS Ankle-Hindfoot Scale improved from 44.7 preoperatively to 77.0 postoperatively (p < 0.01). Subjectively, patients experienced improvements in pain, function, cosmesis, and shoewear. Overall, all patients were satisfied and would have the procedure again under similar circumstances. Radiographically, all parameters statistically improved. There was an increase in arthritic scores for six ankle, six calcaneocuboid, and five midfoot joints. One talonavicular joint nonunion occurred in a rheumatoid patient, requiring revision arthrodesis. CONCLUSIONS: We have concluded that simultaneous arthrodesis of the talonavicular and subtalar joints is a reasonable treatment in the subset of patients with symptomatic hindfoot malalignment whose calcaneocuboid joints are not involved in the primary disease.

The effects of unilateral gastrocsoleus recession.

BACKGROUND: Gastrocsoleus recession is commonly performed to correct equinus contracture of the ankle that may accompany foot and ankle disease in adults. There is concern that mechanical lengthening of the myotendinous unit causes permanent weakness and disability. This retrospective study reviewed the short-term and long-term objective and subjective results of patients who have had this procedure to determine if it is an appropriate adjunct to corrective foot surgery. METHODS: Forty patients who had unilateral gastrocsoleus recession either as an isolated procedure or in conjunction with other surgeries were available for evaluation at an average 25.3 (range 6 to 50) months. Followup evaluation included the AOFAS ankle hindfoot score, subjective questionnaire, and physical examination. Preoperative and postoperative ranges of motion were compared. Mechanical strength testing was done using the contralateral extremity as a control. Maximal strength was measured by peak torque using a Cybex device (CYBEX International, Inc., Ronkonkoma, New York). Fatigue resistance was measured by comparing the maximal number of toe raises between the operative and nonoperative sides. RESULTS: Range of motion improved from -3.5 to 15.3 degrees average dorsiflexion. Subjectively, two patients reported pain at the operative site, and one patient reported moderate weakness. The AOFAS score improved from 62.3 to 79.5. Strength testing of plantarflexion peak torque found the operative extremity to be 74% of the contralateral leg at followup. Peak torque improved from an average of 62.6% at 6 to 18 months to 82.2% after 18 months compared to the contralateral extremity. Fatigue resistance improved from 37.6% to 50.3% at 18 months. Two patients reported paresthesias in the sural nerve distribution. CONCLUSION: Gastrocsoleus recession is an effective procedure to correct equinus contracture either as an isolated procedure or as an adjunct to other foot surgery. While both fatigue resistance and strength decreased initially, both demonstrated improvement over time. Four patients had subjective complaints after the procedure.

Effects of a cyclooxygenase-2 inhibitor (rofecoxib) on bone healing.

In the study reported here, we determined the effects on bone healing of rofecoxib, one of the selective cyclooxygenase-2 (Cox-2) inhibitors that has been used for postsurgical analgesia, and compared these effects with those of nonselective ibuprofen and placebo. Each of 66 male rats received a closed, nondisplaced femoral fracture and was fed rofecoxib, ibuprofen, or placebo for 4 weeks. Results of postsacrifice evaluation showed gross nonunions in 64.7% of rofecoxib rats (P < .0001), 17.6% of ibuprofen rats (P = .007), and 0% of placebo rats. Compared with ibuprofen, rofecoxib was significantly more likely to produce nonunions (P = .007). Mean callus width was 8.9 mm (SD, 1.3 mm) for rofecoxib (P = .03), 8.9 mm (SD, 1.2 mm) for ibuprofen (P = .03), and 8.0 mm (SD, 1.3 mm) for placebo. Mean healing maturity (Goldberg classification) was 1.6 (SD, 0.7) for rofecoxib (P < .0001), 1.7 (SD, 0.8) for ibuprofen (P = .0001), and 2.7 (SD, 0.6) for placebo. Mean fracture angulation was 30.8 degrees (SD, 16.7 degrees) for rofecoxib (P = .003), 14.3 degrees (SD, 14.4 degrees) for ibuprofen (NS), and 13.4 degrees (SD, 10.3 degrees) for placebo. Mean histologic healing was 5.75 for rofecoxib (P = .02), 6.35 for ibuprofen (P = .05), and 8.25 for placebo. Cox-2 inhibitors should be used with caution when bone healing is necessary. Further study is warranted to determine whether the adverse effects occur in humans.