Ankle and Tibiotalocalcaneal Fusion.

Arthrodesis of the ankle and/or tibiotalocalcaneal joints is a reliable treatment of arthritic conditions of the ankle and hindfoot. It may be complicated by infection, nonunion, malunion, fracture, wound complications, nerve injury, and adjacent joint degeneration. These complications may be addressed with a variety of techniques but should be done so carefully so as not to lead to more complex problems. A thorough work-up and discussion should take place prior to any surgical intervention and treatment. Several cases are presented to illustrate revision arthrodesis techniques and the management of these complications.

Bipolar Fresh Osteochondral Allograft Transplantation of the Tibiotalar Joint: A Concise Mid-Term Follow-up of a Previous Report☠.

Despite advances in managing degenerative arthritis of the ankle joint, there are few optimal treatment options for young patients with symptomatic, end-stage degenerative disease. Popular surgical options consist of traditional arthrodesis and, more recently, arthroplasty. Additional techniques, including arthroscopic debridement and joint distraction, have gained little traction. An alternative option is bipolar fresh osteochondral allograft (OCA) transplantation of the tibiotalar joint. We previously reported on a cohort of 86 ankles that had undergone bipolar OCA of the tibiotalar joint and now present the results after longer, mid-term follow-up (mean, 9.2 years) of the same cohort. OCA survivorship was 74.8% at 5 years and 56% at 10 years. Of the patients with a surviving graft, 74% were satisfied with the results. At the latest follow-up, 86% reported better function and 79% reported less pain compared with preoperatively. Bipolar OCA transplantation of the tibiotalar joint is an effective alternative treatment for selected young patients with end-stage ankle arthritis who wish to avoid arthrodesis or prosthetic arthroplasty. LEVEL OF EVIDENCE:: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Large BM Intra-Articular Allograft.

Posttraumatic tibiotalar arthritis is a challenging problem in young, active patients. Many of these patients do not want to pursue ankle arthrodesis after they fail conservative treatment measures, as they wish to preserve joint motion. Osteochondral shell allograft arthroplasty has been described as a reasonable alternative for treating these patients. The procedure itself is technically demanding; however, with improvements in surgical technique and adequate preoperative patient counseling, it provides improvement in ankle function and has good outcomes for most patients at long-term follow-up.

Total Toe Replacement in the United States: What Is Known and What Is on the Horizon.

Arthritis of the first metatarsophalangeal is a common problem of the forefoot. The gold standard surgical treatment has been fusion of the first metatarsophalangeal joint. Many patients are unwilling to accept pain relief at the expense of loss of motion and the corresponding loss of shoe wear choices and activities requiring dorsiflexion of the hallux. Early implants were plagued with loosening and continued pain but implants have evolved. Current implants use modern bearing surfaces with press-fit fixation. These implants have renewed optimism for total toe arthroplasty. This article reviews the literature for implants currently available and describes the surgical techniques.

Osteoarticular transplantation: recognizing expected postsurgical appearances and complications.

Despite technologic advances in prosthetic joint replacement, young patients who have lost a large volume of bone or soft tissue because of a tumor or traumatic injury may not be good candidates for prosthetic implants, which have limited longevity relative to that of biologic tissue grafts. In recent years, the use of biologic materials in orthopedic surgery has increased. Such materials, known as allografts, consist of cadaveric bone, cartilage, and other soft tissues that can be transplanted into a living patient. Alternatively, osteochondral autografts, or autologous grafts of the patient's own bone and/or cartilage, can be harvested from one body site and transplanted to another. Surgical procedures range from the local implantation of small osteochondral plugs to the replacement of entire joints with allografts. The size of the allograft used depends on the amount of bone and soft tissue needed. The use of allografts in patients with large-volume bone loss often preserves limb function, obviating amputation, which makes it an attractive option for treatment of young patients. Advantages of using allografts include the similarity of graft materials to native tissues and the decreased patient morbidity in the absence of an autograft donor site; disadvantages include slower biologic remodeling and graft incorporation than are typical with the use of autologous grafts. Potential complications of allograft tissue implantation include graft nonunion, collapse, and failure; infection; and secondary osteoarthritis. The article discusses the indications for and basic steps involved in each type of transplant procedure, normal pre- and postoperative imaging appearances, and imaging features that may be indicative of transplant complications.

Intraoperative and perioperative complications during revision arthroplasty for salvage of a failed total ankle arthroplasty.

BACKGROUND: Revision of a failed total ankle arthroplasty (TAA) remains a challenge. Advances in total ankle implant design have renewed interest in revision TAA as an alternative to ankle arthrodesis or amputation in the management of a failed TAA. The purpose of our study was to review a series of failed Agility TAA revised to INBONE II TAA and identify reasons for revision as well as perioperative complications. METHODS: A retrospective review of 35 cases of failed Agility TAA revised to an INBONE II TAA was performed at 1 institution. Patient demographics, indications for revision, radiographs, and complications were reviewed. The average follow-up was 9.1 months (range, 0-28 months). All revisions were performed by 1 of 2 foot and ankle surgeons familiar with both prostheses. RESULTS: The Agility TAA lasted a mean of 6.7 years prior to revision to an INBONE II TAA. Revision TAA was indicated due to mechanical loosening, osteolysis, periprosthetic fracture, and a dislocated prosthesis. Adjunctive procedures were performed in 31 of 35 cases. There were 6 intraoperative and 5 acute postoperative complications, leading to an overall 31.4% complication rate. There was 1 patient with continued pain postoperatively who underwent a second revision of the INBONE II 20 months postoperatively. CONCLUSION: Revision TAA was a viable treatment option for failed TAA. A high risk of perioperative complications remains, and physicians should be aware of the challenges that occur during these procedures in order to plan for them preoperatively. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Epidemiology and imaging appearance of the normal Bi-/multipartite hallux sesamoid bone.

BACKGROUND: Turf toe is a hyperextension injury of the hallux metatarsophalangeal joint that can be difficult to diagnose on physical examination and imaging. Diastasis of the bi- or multipartite sesamoid of the hallux has been implicated as 1 potential radiographic finding of turf toe injury, and when present may require operative management. However, the normal interval for the bi-/multipartite sesamoid has not yet been established. METHODS: A total of 671 foot radiograph series were reviewed in effort to quantify the dominant interval of the bi-/multipartite sesamoid bone with respect to potential influencing factors including right versus left foot, medial and/or lateral sesamoid involvement, patient age and gender, and weight versus non-weight-bearing radiograph technique. RESULTS: The prevalence of a bi-/multipartite hallux sesamoid was 14.3% in our population. The dominant sesamoid interval ranged from 0-2 mm, with an average of 0.79 mm. CONCLUSION: We conclude that sesamoid diastasis should be considered, in the appropriate clinical setting, when the sesamoid interval is greater than 2 mm on a routine AP radiograph of the foot. LEVEL OF EVIDENCE: Level III, comparative study.

Triple arthrodesis: tips and tricks to navigate trouble.

Triple arthrodesis is a powerful corrector of hindfoot deformity related to trauma, rheumatoid arthritis, and long-standing peritalar subluxation with posterior tibial tendon dysfunction. To avoid the common postoperative complications related to triple arthrodesis, one must be meticulous in preoperative evaluation as well as surgical technique. Presented are some tips and tricks to avoid the common complications and provide the patient with a plantigrade, stable foot, as well as some salvage options for triple arthrodesis in a malunited position.

Bipolar Osteochondral Allograft Transplantation of the Tibiotalar Joint for Ankle Arthritis.

INTRODUCTION: Bipolar osteochondral allografting is a technically complex procedure envisioned as an alternative to arthrodesis or arthroplasty1 in carefully selected young patients with advanced tibiotalar arthritis, usually as a result of trauma. STEP 1 PREOPERATIVE PLANNING: Confirm that the grafts are not damaged and that the side (left or right) and size (not too small) are properly matched to the donor. STEP 2 PLACEMENT OF THE EXTERNAL FIXATOR: Place an external fixator across the ankle joint using fluoroscopy and distract the ankle prior to incision. STEP 3 ANTERIOR APPROACH TO THE ANKLE: Perform a standard anterior approach to the ankle joint. STEP 4 POSITIONING OF THE CUTTING JIG: Mount the jig on the ankle and confirm the cutting block position both visually and fluoroscopically. STEP 5 BONE RESECTION: Using a reciprocating saw and careful technique to protect the tendons and neurovascular structures, perform osseous resection of the distal part of the tibia and the talar dome. STEP 6 PREPARATION OF THE ALLOGRAFT: Prepare the tibial and talar allografts from the donor tissue to match the resection gap created in Step 5. STEP 7 INSERTION AND FIXATION OF THE ALLOGRAFT: Insert and fix the allograft construct and remove the external fixator. STEP 8 REHABILITATION: Postoperative care is straightforward, including initial immobilization and a three-month period of non-weight-bearing. RESULTS: In our recent clinical study2, we used our clinical outcomes database to identify eighty-four consecutive patients (eighty-eight ankles) who underwent bipolar osteochondral allograft transplantation of the tibiotalar joint, had surgery in 1999 or later, and had not had a previous arthroplasty or osteochondral allograft transplantation involving the tibial plafond and/or talus.IndicationsContraindicationsPitfalls & Challenges.

Bipolar fresh osteochondral allografting of the tibiotalar joint.

BACKGROUND: Tibiotalar arthritis in the young, active patient is a debilitating condition with limited treatment options. Bipolar tibiotalar fresh osteochondral allograft transplantation was conceived as a possible alternative to arthrodesis and arthroplasty. We reported our experience with bipolar ankle osteochondral allografts for the treatment of tibiotalar joint arthritis. METHODS: Between 1999 and 2008, we performed bipolar ankle allografts in eighty-eight ankles (eighty-four patients). Eighty-six ankles (eighty-two patients) had a minimum follow-up duration of two years. The mean patient age was forty-four years and 52% of the patients were male. Evaluation included frequency and type of reoperations, the Olerud-Molander Ankle Score, pain, function, and patient satisfaction. Radiographs were evaluated for graft healing, joint space narrowing, and graft collapse. RESULTS: The mean duration of follow-up was 5.3 years (range, two to eleven years). Thirty-six (42%) of the eighty-six ankles that had undergone allograft had further surgery since implantation. Of the eighty-six ankles, twenty-five ankles (29%) had undergone graft-related reoperations and were considered clinical failures (ten underwent revision allografts, seven underwent arthrodeses, six underwent conversions to total ankle arthroplasty, and two underwent below-the-knee amputations) and eleven ankles (13%) had had reoperations that were not necessarily related to the graft (e.g., implant removal, debridement, synovectomy, or distraction). Survivorship of the osteochondral allograft was 76% at five years and 44% at ten years. The mean Olerud-Molander Ankle Score was 61 points at the time of the latest follow-up. The majority of patients reported satisfaction (92%) with osteochondral allograft transplantation and less pain (85%) and improved function (83%) after the procedure. CONCLUSIONS: Transplantation of a fresh bipolar ankle osteochondral allograft for the treatment of tibiotalar arthritis resulted in acceptable outcomes in this difficult population, with most patients having improved objective and subjective outcome measures. Subjective satisfaction was high in spite of the 29% clinical failure rate. Osteochondral allograft failure did not limit further surgical options. We concluded that transplantation of a bipolar ankle allograft is a useful alternative in carefully selected patients with advanced tibiotalar arthritis.

Surgical treatment of the ankle and foot in patients with rheumatoid arthritis.

Rheumatoid arthritis can be as devastating for the joints of the foot and ankle as for other joints of the lower and upper extremities. Early conservative treatment often is provided by a primary care provider or rheumatologist. Drug and injection therapies are used with footwear modifications, activity restrictions, and orthoses. Surgery often is the last treatment modality available to the patient; it has the potential to relieve pain and improve function.

Chondrocyte viability after intra-articular calcaneal fractures in humans.

BACKGROUND: Chondral damage from the impact of injury may contribute to the high incidence of post-traumatic arthritis after calcaneal fractures, but this has yet to be proven. We sought to study the effect of intra-articular calcaneal fractures on chondrocyte viability and to correlate these effects with injury severity, time from injury to surgery, and patient age and co-morbidities. METHODS: Irreducible osteochondral fragments from 12 patients undergoing operative treatment for intra-articular calcaneal fractures were analyzed. Control cartilage was obtained from four tissue donors who died of unrelated causes. The cartilage was assessed for chondrocyte viability through the full thickness of tissue using a Live/Dead assay followed by laser scanning confocal microscopy. Patient demographics including injury classification and severity, time from injury to surgery, and patient age were recorded. RESULTS: Chondrocyte viability from fracture patients averaged 72.8% +/- 12.9% (range 53% to 95%), which was significantly lower than the 94.8% +/- 1.5% viability observed in the control specimens (p = 0.005). Chondrocyte viability declined with higher energy injuries (p = 0.13), time from injury to surgery (p = 0.07), and increasing patient age (p = 0.07). However, none of these factors reached a level of statistical significance. CONCLUSIONS: A significant decline in chondrocyte viability occurs after intra-articular fractures of the calcaneus. This may contribute to the development of post-traumatic arthritis.

Efficacy of surgical preparation solutions in foot and ankle surgery.

BACKGROUND: Previous studies have demonstrated higher infection rates following orthopaedic procedures on the foot and ankle as compared with procedures involving other areas of the body. Previous studies also have documented the difficulty of eliminating bacteria from the forefoot prior to surgery. The purpose of the present study was to evaluate the efficacy of three different surgical skin-preparation solutions in eliminating potential bacterial pathogens from the foot. METHODS: A prospective study was undertaken to evaluate 125 consecutive patients undergoing surgery of the foot and ankle. Each lower extremity was prepared with one of three randomly selected solutions: DuraPrep (0.7% iodine and 74% isopropyl alcohol), Techni-Care (3.0% chloroxylenol), or ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol). After preparation, quantitative culture specimens were obtained from three locations: the hallux nailfold (the hallux site), the web spaces between the second and third and between the fourth and fifth digits (the toe site), and the anterior part of the tibia (the control site). RESULTS: In the Techni-Care group, bacteria grew on culture of specimens obtained from 95% of the hallux sites, 98% of the toe sites, and 35% of the control sites. In the DuraPrep group, bacteria grew on culture of specimens obtained from 65% of the hallux sites, 45% of the toe sites, and 23% of the control sites. In the ChloraPrep group, bacteria grew on culture of specimens from 30% of the hallux sites, 23% of the toe sites, and 10% of the control sites. ChloraPrep was the most effective agent for eliminating bacteria from the halluces and the toes (p < 0.0001). CONCLUSIONS: The use of effective preoperative preparation solution is an important step in limiting surgical wound contamination and preventing infection, particularly in foot and ankle surgery. Of the three solutions tested in the present study, the combination of chlorhexidine and alcohol (ChloraPrep) was most effective for eliminating bacteria from the forefoot prior to surgery.

Use of allografts in the management of ankle arthritis.

Reconstruction of articular cartilage defects of the tibiotalar joint remains a challenge. Although arthrodesis and total ankle arthroplasty are treatment options, we present fresh tibiotalar allografting as an alternative technique. The average age of 12 patients who underwent tibiotalar allografting was 43 years. The average follow-up was 21 months. All grafts healed at the host/donor interface. Complications included intraoperative fracture in one patient and graft collapse that required revision allografting in another. Most patients were relieved of preoperative pain and were satisfied with the procedure. Postoperative function was also significantly improved, based on questionnaire and physician assessment. Fresh tibiotalar allografting is an exciting and promising technique in the treatment of articular cartilage defects in young, active patients.

Bacterial skin contamination after surgical preparation in foot and ankle surgery.

An effective presurgical preparation is an important step in limiting surgical wound contamination and preventing infection. The purpose of this study was to evaluate residual bacterial skin contamination after surgical skin preparation in foot and ankle surgery to determine if current techniques are satisfactory in eliminating harmful pathogens. Fifty consecutive patients having surgical procedures of the foot and ankle were studied. Each lower extremity was prepared randomly with either a one-step povidone-iodine topical gel or a two-step iodophor scrub followed by a povidone-iodine paint. After preparation and draping, cultures were obtained at three locations: the hallux nailfold, web space between the second and third, and fourth and fifth toes, and the anterior ankle (control). In the gel group, positive cultures were obtained from 76% of halluces, 68% of toes, and 16% of controls. In the scrub and paint group, positive cultures were obtained from 84% of halluces, 76% of toes, and 28% of controls. Numerous pathogens were cultured, with Staphylococcus epidermidis being the most prevalent. Based on the findings of the current study, presurgical skin preparation with a povidone-iodine based topical bactericidal agent is not sufficient in eliminating pathogens in foot and ankle surgery. The unique environment of the foot and its resident organisms may play a role in the higher infection rates associated with surgery of the foot and ankle.

Posterior tibialis tendon tears: comparison of the diagnostic efficacy of magnetic resonance imaging and ultrasonography for the detection of surgically created longitudinal tears in cadavers.

RATIONALE AND OBJECTIVES: The optimal advanced imaging method for detection and characterization of posterior tibialis tendon (PTT) tears is unclear. The purpose of this study was to investigate the utility of ultrasonography (US) and MR imaging in the detection of surgically created PTT tears in cadavers. MATERIALS AND METHODS: This was a prospective blinded study in which 16 fresh cadaveric foot and ankle specimens (3 men, 13 women; average age at death 83.9 years; age range 71-96 years) were scanned with both US and MR imaging before and after the surgical creation of 64 variable length longitudinal tears of the PTT. Ultrasonography was performed with a 12 MHz linear transducer with independent interpretations of static and dynamic studies separately by two blinded and experienced musculoskeletal radiologists. MR imaging was performed at 1.5 T with a standard transmit-receive extremity coil using axial, sagittal, coronal T1-weighted (TR 600, TE 20), and axial fast spin echo proton density and T2-weighted (TR 3000, TE 161/20, ETL 12) images. MR images were reviewed independently by two experienced musculoskeletal radiologists who were blinded to the status of the PTT. RESULTS: Sensitivity, specificity, and accuracy of MR imaging in the diagnosis of PTT tears were 73%, 69%, and 72%, respectively. Dynamic US interpretation yielded values of 69% sensitivity, 81% specificity, and 72% accuracy. Static US interpretation was less reliable than dynamic interpretation, and the only significance of static imaging was a high specificity (94%) for detection of longitudinal tears. The positive predictive value (PPV) for MR imaging and US was 88% and 92% respectively, and the negative predictive value (NPV) was 46% for both MR imaging and US. CONCLUSION: Our results suggest that US and MR imaging perform at the same level for the detection of surgically created longitudinal PTT tears in a cadaveric model. US has a higher specificity compared with MR imaging.

Treatment of post-traumatic ankle arthrosis with bipolar tibiotalar osteochondral shell allografts.

We report on tibiotalar osteochondral shell allografts for post-traumatic ankle arthropathy in seven patients. Average follow-up was 148 months (range, 85 to 198). Patients were evaluated by a questionnaire, SF-12 survey, ankle score, physical exam and radiographs. The ankle score increased from 25 preoperatively to 43 at latest follow-up (maximum score 100). SF-12 scores increased from 30 to 38 (Physical Component) and 46 to 53 (Mental Component). The failure rate was 42%. Four of seven patients reported good or excellent results. Five patients stated they would undergo a similar procedure again. Complications included graft fragmentation, poor graft fit, graft subluxation, and non-union. Follow-up radiographs demonstrated joint space narrowing, osteophytes, and sclerosis, even in cases with excellent clinical status. Fresh osteochondral shell allografting may provide a viable alternative for the treatment of post-traumatic ankle arthrosis in selected individuals.

Surgical options for salvage of end-stage hallux rigidus.

When approaching patients with a painful first MTP joint that has failed conservative therapy and first-line surgical treatments (cheilectomy or minor bunion procedures), the surgeon should stratify these patients based upon diagnosis, age, and activity level (Fig. 13). For the young, active patient, an arthrodesis is the gold standard, and the primary predictors of clinical and radiographic success are proper fusion angle alignment and maintenance or restoration of length. The method of fusion site preparation and the choice of fixation have not been found to be significant factors in achieving union, but based on the biomechanical data, we prefer the cup-and-cone method. Young, active patients with hallux rigidus also may be considered candidates for the investigational biologic interpositional arthroplasty procedures. Minimizing the bony resection and interposing soft tissue into the first MTP joint may provide symptomatic relief and maintain or restore motion and strength. Most importantly, this procedure does not seem to burn any bridges. If it fails, these patients can then be revised to an arthrodesis. In the elderly, inactive patient, arthrodesis is a safe and reliable treatment option. The Keller arthroplasty may be preferable, however, because it provides [figure: see text] excellent early symptomatic relief and has a less debilitating postoperative rehabilitation program. After Keller arthroplasty, patients may begin protected weight bearing immediately and after wound healing, may be advanced to weight bearing as tolerated. Whereas after fusion, most authors agree that patients should be nonweight bearing for 4-6 weeks or until there is some evidence of early radiographic union. In an older patient with inadequate upper extremity strength to manage crutches or a front-wheel walker, a first MTP fusion may result in prolonged confinement to a wheelchair. If the patient elects to undergo the Keller procedure, these patients should be counseled preoperatively about the potential complications of transfer metatarsalgia, cock-up deformity of the hallux, and weakness in the push-off phase of gait. The patients between these two extremes fall into a treatment gray zone. The arthrodesis should again be considered the gold standard because it is reliable and durable with time and activity. However, biologic or prosthetic interpositional arthroplasty are exciting investigational treatment options for these patients. If a prosthetic implant is to be used, the double-stemmed, hinged silastic implant with protective titanium grommets, or a metallic hemi-arthroplasty prosthesis, appear to be the two best choices of implant. With the continuous advances in material engineering and tissue engineering, prosthetic and biologic interpositional arthroplasties hold the greatest promise for the painful first MTP joint in the future. These treatment modalities allow restoration of alignment and maintenance of motion, length, and strength, which are fundamental in attaining a good clinical result. When the optimal material is developed (whether it is prosthetic, biologic, or a combination of both), these treatment advantages will be realized without the attendant complications associated with the use of our current implants.