Early weightbearing of the Lapidus bunionectomy: is it feasible?

The Lapidus procedure should no longer be considered a strict nonweightbearing bunionectomy. In the past few years, several studies have emerged demonstrating that early weightbearing after a Lapidus fusion is indeed possible with satisfactory fusion rates. This is mainly because of improved fixation techniques available today, which have allowed for better stabilization of the fusion site. Surgeons should still properly indicate patients for early weightbearing protocols.

Early weight bearing after modified lapidus arthodesis: a multicenter review of 80 cases.

The modified Lapidus arthrodesis involves fusion of the first tarsometatarsal, which typically takes about 6 weeks to consolidate. Postoperative protocols typically involve non-weight bearing until bone consolidation occurs, however, with a stable fixation construct, protected weight bearing can be initiated earlier than 6 weeks into the postoperative period. Studies specifically evaluating an early weight bearing protocol after lapidus arthrodesis do not exist; such a protocol is the focus of this investigation. A multicenter retrospective review of 80 feet in 76 patients who underwent a Lapidus arthrodesis by 2 different surgeons, involving a similar fixation technique and an early weight-bearing protocol, was performed. All patients were allowed protected weight bearing after the first postoperative visit, at approximately 2 weeks into the postoperative course. Patients began protected weight bearing at a mean 14.8 (95% CI 14.0, 15.6) days postoperative. All 80 feet proceeded to successful union (100% union), and the mean time to union was 44.5 days (95% CI 43.0, 46.0). No hardware was broken, and no complications requiring surgical revision were observed before solid boney fusion was achieved. Statistically significant (P < .001) improvements in the first intermetatarsal, hallux abductus, and lateral metatarsal angles were observed; and no cases of pathological first ray elevatus were encountered. The duration of time to bone healing in the cohort described in this article was similar to the rates described in previous reports describing Lapidus arthrodesis managed with a considerably longer duration of initial postoperative non-weight bearing. This study demonstrates that early weight bearing of the Lapidus arthrodesis can be performed without compromising correction or the rate of osseous union. This is the first study that specifically evaluates the early weight bearing protocol after lapidus arthrodesis.

Flexible pediatric and adolescent pes planovalgus: conservative and surgical treatment options.

Pediatric and adolescent flexible flatfoot is a pathomechanically complex deformity. Conservative and surgical treatment is directed at realigning the foot and alleviating symptoms. When surgical intervention is considered, there are various methods and techniques that may be performed to realign the foot. The treatment goals are directed first at resolution of pain, and second at the realignment of the foot. A specific treatment algorithm does not exist, although planal dominance influences direct the surgeons when considering surgical intervention. Open physis often dictates the direction of the reconstruction. Attempts at essential joint preservation should be strongly considered in this young patient population. This article provides an overview of the common treatment pathways that highlight methods to structurally realign the pediatric and adolescent flatfoot.

Pediatric & adolescent flatfoot reconstruction in combination with middle facet talocalcaneal coalition resection.

Surgical reconstruction of symptomatic flatfoot associated with middle facet tarsal coalition is becoming more widely used. This article demonstrates that coalition-concomitant flatfoot is a pathologic entity that is worthy of surgical management. The literature, although limited, has suggested that poor outcomes with isolated simple coalition resection may have been related to the preoperative pes planus that was not addressed. More recently studies have demonstrated improved clinical and radiographic postoperative outcomes when the flatfoot correction is combined with the coalition resection. This article reviews a surgical treatment algorithm that considers the presence of varying degrees of pes planus and rearfoot arthrosis associated with coalition.

A critical evaluation of subtalar joint arthrosis associated with middle facet talocalcaneal coalition in 21 surgically managed patients: a retrospective computed tomography review. Investigations involving middle facet coalitions-part III.

Symptomatic middle facet talocalcaneal coalition is frequently associated with rearfoot arthrosis that is often managed surgically with rearfoot fusion. However, no objective method for classifying the extent of subtalar joint arthrosis exists. No study has clearly identified the extent of posterior facet arthrosis present in a large cohort treated surgically for talocalcaneal coalition through preoperative computerized axial tomography. The authors conducted a retrospective review of 21 patients (35 feet) with coalition who were surgically treated over a 12-year period for coalition on at least 1 foot. Using a predefined original staging system, the extent of the arthrosis was categorized into normal or mild (Stage I), moderate (Stage II), and severe (Stage III) arthrosis. The association of stage and age is statistically significant. All of the feet with Stage III arthrosis had fibrous coalitions. No foot with osseous coalition had Stage III arthrosis. The distribution of arthrosis staging differs between fibrous and osseous coalitions. Only fibrous coalitions had the most advanced arthrosis (Stage III), whereas osseous coalitions did not. This suggests that osseous coalitions may have a protective effect in the prevention of severe degeneration of the subtalar joint. Concomitant subtalar joint arthrosis severity progresses with age; surgeons may want to consider earlier surgical intervention to prevent arthrosis progression in patients with symptomatic middle facet talocalcaneal coalition.

The versatility of the Lapidus arthrodesis.

Lapidus Arthrodesis is probably the most versatile procedure of the foot and ankle surgeon. The procedure was conceived initially for the surgical treatment of met primus adductus associated with hallux valgus, but has also been used for the treatment of a variety of other conditions including hallux limitus, revision bunion surgery, medial column stabilization, and others. Although the use of the Lapidus in bunion surgery is well supported in the literature, surgeons have been expanding its indications to manage a variety of disorders affecting the foot. As more surgeons continue to gain experience with the procedure, additional studies will emerge, further supporting its versatility in the realm of foot surgery.

Magnetic resonance imaging of a deep peroneal intraneural ganglion cyst originating from the second metatarsophalangeal joint: a pattern of propagation supporting the unified articular (synovial) theory for the formation of intraneural ganglia.

UNLABELLED: A deep peroneal intraneural cyst of the first web space of the foot is presented. Analysis of the magnetic resonance image scans revealed not only a connection with the medial aspect of the second metatarsophalangeal joint, but also the presence of an interconnected cyst within the lateral digital branch of the hallux. These characteristic magnetic resonance image findings are consistent with those previously described for a peroneal intraneural ganglion cyst that arose from the superior tibiofibular joint, and include (1) origin (ascent) from the second metatarsophalangeal joint with propagation along the articular branch and into the dorsal digital branch of the second toe, (2) cross-over within the shared epineurial sheath of the deep peroneal nerve, and (3) further propagation (descent) within the dorsal digital branch of the hallux. The analogous features between intraneural ganglion cysts affecting small and large-caliber nerves support the fundamental principles of the unified articular (synovial) theory for the formation of intraneural ganglia, including (1) a connection to a synovial joint, (2) dissection of joint fluid through a capsular rent along the articular branch into the parent nerve, and (3) intra-epineurial, pressure-dependent propagation of cyst fluid along paths of least resistance. LEVEL OF CLINICAL EVIDENCE: 4.

The presence of calcaneal fibular remodeling associated with middle facet talocalcaneal coalition: a retrospective CT review of 35 feet. Investigations involving middle facet coalitions--Part II.

Middle facet talocalcaneal coalition is often associated with a rigid pes planovalgus. In the presence of calcaneal valgus, the fibula may come into contact with the lateral calcaneal wall during weight bearing, and develop a pseudoarticulation. Spurring, bone cysts, and other morphologic changes may concomitantly occur at the calcaneus and fibula, suggesting a pathological degenerative process. This association has not been previously studied in middle facet tarsal coalition and we term the condition calcaneal fibular remodeling, the focus of this investigation. To our knowledge, no study has specifically looked at the abutment of the calcaneus and fibula as an additional area of pathology in patients treated operatively for tarsal coalition. Computerized axial tomography was retrospectively reviewed in 21 patients (35 feet) with symptomatic middle facet talocalcaneal coalition who were surgically treated for the coalition on at least 1 foot over a 12-year period. In 19 (54%) of the 35 feet, calcaneal fibular remodeling was identified and associated with concomitant coalition and pes planovalgus deformity. Fifteen (79%) of the 19 feet with calcaneal fibular remodeling were managed surgically at the time of manuscript submission for middle facet talocalcaneal coalition. This new finding suggests that simple resection of the coalition may not fully address the entire deformity and other combined surgical approaches may be more appropriate in the face of middle facet talocalcaneal coalition with heel valgus and calcaneal fibular remodeling.

Interposition of the flexor hallucis longus tendon through the subtalar joint as a late complication of pediatric clubfoot repair: a case report.

Interposition of the flexor hallucis longus tendon through the subtalar joint was identified intraoperatively during a triple arthrodesis for a symptomatic adult clubfoot in a patient who had a posteromedial release as a child. The mechanism for this occurrence is unknown, although it is likely that the flexor hallucis longus tendon deviated into the subtalar joint during the early postoperative period. Interposition of the flexor hallucis longus tendon has not been previously reported as a late complication of pediatric clubfoot repair.

Giant extraskeletal osteochondroma of the plantar midfoot arch.

Osteochondromas found within the soft tissue without osseous or intra-articular involvement are better described as extraskeletal osteochondromas. They are slow-growing, benign, osseous tumors, and are often misdiagnosed as conventional osteochondromas. Though extraskeletal osteochondromas are rare, they typically affect the digits of the hands or feet. We present a patient with a giant symptomatic extraskeletal osteochondroma that developed in the plantar medial longitudinal arch of the foot. To the authors' knowledge, this is the largest isolated extraskeletal osteochondroma in the arch of the foot identified in the literature. The diagnosis of an extraskeletal osteochondroma should be considered when a well-defined osseous mass occurs in the soft tissue.

Bilateral single-stage middle facet talocalcaneal coalition resection combined with flatfoot reconstruction: a report of 3 cases and review of the literature. Investigations involving middle facet coalitions--part 1.

UNLABELLED: Talocalcaneal middle facet coalitions are associated with rigid pes planovalgus that often requires surgical intervention. Simple resection of the coalition is preferred for symptomatic cases in the absence of rearfoot arthritis. While resection of the coalition will remove the osseous restriction of motion and may eliminate pain, the procedure does not specifically correct the concomitant pes planovalgus. In this report of 6 feet in 3 patients, we advocate combining resection of the coalition with concomitant flatfoot reconstruction in a single-stage operation. The patients in this series averaged 13.67 (range 12-17) years of age at the time of their foot surgeries, and their follow-up averaged 30 (range 16-54) months. All of the patients displayed bilateral middle facet talocalcaneal coalitions and underwent bilateral resection combined with flatfoot reconstruction. Each patient had 1 foot corrected followed by a period of at least 6 months before the contralateral foot was corrected. The mean postoperative American Orthopaedic Foot and Ankle Society ankle-hindfoot score was excellent (94.33+/-2.81 points) overall. The median radiographic values for calcaneal inclination, Meary's, and anteroposterior talar-first metatarsal angles demonstrated statistically significant improvements: 9 degrees (3 degrees, 13 degrees) (P= .0273), 4 degrees (2 degrees, 7 degrees) (P= .0269), and 6 degrees (3 degrees, 11 degrees ) (P= .0277), respectively, and all feet demonstrated improved subtalar joint motion without pain. Although long-term results remain to be determined in a larger cohort, it is hoped that this combined approach to talocalcaneal coalition will delay or obviate future rearfoot arthrosis and the need for arthrodesis. LEVEL OF CLINICAL EVIDENCE: 4.

Giant solitary osteochondroma of the inferior medial calcaneal tubercle: a case report and review of the literature.

UNLABELLED: Small osteophytes are frequently encountered in the foot and ankle, and are not to be confused with true osteochondromas, which are relatively uncommon in this region. They most often affect long bones of the appendicular skeleton but may involve flat bones as well. Osteochondromas are benign osseous neoplasms with a distinct hyaline cartilage cap originating from the physis and cease growing with skeletal maturity. Osteochondroma are often treated conservatively unless they become symptomatic, painful, demonstrate rapid or new growth, enlarge after skeletal maturity, and/or exhibit signs of malignant transformation. In this report, we present a case of a giant (8 cm x 4.2 cm x 2.1 cm) osteochondroma in an adult occurring on the inferior medial tubercle of the calcaneus that underwent excision, with 3.5 years of follow-up without recurrence. To our knowledge this is the largest osteochondroma affecting the inferior medial tubercle of the calcaneus. This case demonstrates that large osteochondromas may occur in the foot, and also confirms that benign osteochondroma growth may occur in adulthood. A detailed review of osteochondroma occurrence in the foot is presented along with a review of the diagnostic work-up to evaluate for malignant transformation. LEVEL OF CLINICAL EVIDENCE: 4.

A posttraumatic, joint-connected sural intraneural ganglion cyst-with a new mechanism of intraneural recurrence: a case report.

UNLABELLED: Intraneural ganglion cysts are rare in occurrence and most commonly involve the peroneal nerve at the fibular neck. We present a case of a traumatically induced intraneural ganglion cyst of the sural nerve that developed after a nondisplaced posterior malleolus ankle fracture. The intraneural ganglion cyst was connected to the subtalar joint by its articular branch and ascended several centimeters into the distal fourth of the leg. It was resected from the sural nerve proper and the posterior branch of the lateral calcaneal nerve, and the articular trunk was ligated. The patient developed subclinical intraneural recurrence, which was detected on a postoperative magnetic resonance imaging (MRI). Retrospective reinterpretation of the preoperative and postoperative MRIs revealed that ligation of the articular trunk proximal to a major branch (ie, the anterior branch of the lateral calcaneal nerve) led to increased intraneural cyst propagation distally: within the blind stump of the articular trunk and within several anterior branches of the lateral calcaneal nerve but not within the parent sural nerve or its continuation, the lateral dorsal cutaneous nerve. This mode of intraneural, but extraparental nerve recurrence can be easily understood by considering the altered fluid dynamics, particularly the increased resistance. This case report provides further evidence not only supporting the articular theory of intraneural ganglion formation but also highlighting the importance of searching for, identifying, and treating the pathologic articular branch connection near its joint connection in all cases. LEVEL OF CLINICAL EVIDENCE: 4.

Anatomical aspects of the gastrocnemius aponeurosis and its muscular bound portion: a cadaveric study-part II.

Gastrocnemius intramuscular aponeurotic recession is performed on the anterior surface of the muscular-bound portion of the gastrocnemius aponeurosis, in the "transection zone" located inferior to the region where the aponeurosis is formed by the separate tendons of the medial and lateral heads of gastrocnemius, and superior to the inferior portions of the muscle's 2 heads. Measurements showed the mean proximal-to-distal length of the transection zone to be 50 mm (range 7 to 100 mm), and the mean width was 88 mm (range 48 to 19 mm). The part of the aponeurosis associated with the medial head contributed 60% of the width of the transection zone (mean 53 mm, range 30 to 80 mm), and the lateral head contributed 40% (mean 35 mm, range 18 to 53 mm). The mean lengths of the parts of the medial and lateral heads that were inferior to the transection zone were 40 mm (range 16 to 68 mm) and 22 mm (range 6 to 35 mm), respectively. In theory, a distal transection will have a large biomechanical effect, releasing more gastrocnemius fibers from their plantarflexory action; whereas a proximal transection will have less effect. An oblique incision or step-cut positioned distally on the medial side may be appropriate if the transection zone is short, if the transection is far distal in the zone, and/or if the medial head extends far distal to the lateral head.

Hemorrhagic ganglion of the tibialis anterior tendon: report of an unusual variant.

While clinicians have encountered heme-laden ganglion cysts in the past, to our knowledge the condition has never been described in the literature as a distinct pathological entity, namely, the hemorrhagic ganglion. Because hemorrhage may alter the appearance of an aspirate obtained from a ganglion cyst, and hemosiderin deposition within a ganglion cyst may alter the signal characteristics observed on a magnetic resonance image, such that both of these diagnostic methods may suggest the presence of a solid mass tumor rather than a ganglion cyst, it is important for clinicians and surgeons to be aware of the possibility of the presence of a hemorrhagic ganglion cyst. In this report, we present a case wherein a hemorrhagic ganglion cyst of the tibialis anterior tendon was identified and excised.

Bilateral peroneus longus tendon rupture through a bipartite os peroneum.

Peroneus longus rupture with associated involvement of the os peroneum is an uncommon injury, and a small number of cases have been reported. Several mechanisms of injury have been suggested, but the most accepted theory is due to an inversion force placed on a cavovarus foot type. The sesamoid often becomes the focal point of the mechanical stresses and may fracture. Although the purpose of the sesamoid is to protect the tendon from rupture, the os peroneum may actually encourage fatigue (tear/rupture) under certain circumstances. Because this injury occurs at the cuboid notch, primary repair is complicated because of the inability to access the tendon as it courses deep within the midfoot. We present a bilateral case of peroneus longus rupture with involvement of the os peroneum in a patient with a cavovarus foot type. The injuries were sustained from an identical mechanism and occurred almost 1 year apart. In both situations, a peroneus longus to peroneus brevis tendon transfer was performed above the ankle joint in conjunction with partial excision of the fractured os peroneum. To the authors' knowledge, this is the only reported case of peroneus longus rupture associated with fracture of the os peroneum to occur bilaterally.