Bone graft in hindfoot arthrodesis: allograft vs autograft.

From 1990 to 1992, all arthrodeses of the so-called triple joints, combined or isolated and performed by one surgeon, were reviewed to allow a minimum follow up of 18 months from the time of the index procedure. Type of bone graft was selected based on the patients' decision after the risks of each were explained by the surgeon. There were 37 patients undergoing 41 procedures (4 bilateral) including double and triple arthrodesis, as well as isolated subtalar fusions. Twenty-nine of these were performed for either degenerative or posttraumatic arthritis. Ten others were performed for joint incongruity resulting from posterior tibial tendon insufficiency, and the rest for hemiparesis or residual clubfoot. All patients were placed into a routine postoperative regimen of casting, bracing, weight bearing, and therapy. They were evaluated based on subjective complaints, physical examination, and postoperative radiographs. Any patient suspected of having a nonunion underwent a computed tomography scan for confirmation. Overall, 24 patients received allografts and 17 iliac crest grafts. There were four nonunions, three of which utilized banked bone graft, with the only nonunion in the autograft group occurring in a patient following open calcaneus fracture. Of the four nonunions, three opted for revision surgery and the only one to choose allograft again incurred the only recurrent nonunion. There were two infections, one in each group, resulting in prolonged intravenous antibiotic therapy.

Fixation of the Chevron osteotomy utilizing absorbable polydioxanon pins.

The Chevron osteotomy has become popular for the treatment of hallux valgus deformity. Displacement of the osteotomy is a known complication. Many methods of internal fixation have previously been reported to prevent the displacement and each has inherent advantages and disadvantages. An alternative method of fixation, utilizing absorbable polydioxanon pins, is presented in this article. Between April 1989 and April 1990, 71 procedures were performed on 50 patients. At 1-year follow-up, there were no complications or infections. Review of the osteotomy after surgery and at 1 year revealed no fractures or displacements, and no pins required removal. Internal fixation utilizing absorbable polydioxanon pins appears to have significant benefits when compared with metallic fixation.

Arthrodesis of the ankle with lateral plating.

A modification of internal fixation compression arthrodesis for ankle fusion is described using two 6.5-mm cancellous bone screws and a lateral T plate. Using this technique, 20 consecutive arthrodeses by one surgeon were reviewed. Solid union was attained in 19 of 20 patients (95%). Average follow-up was 18 months (range 6-59 months). Time to obtain solid arthrodeses averaged 18 weeks. In 11 patients who returned for follow-up, clinical grading using the Mazur scale score averaged 70 of 90 points. Diagnoses included posttraumatic degenerative arthritis, failed ankle arthrodesis and rheumatoid arthritis (2 each), failed ankle arthroplasty, and post-tuberculous arthritis (1 each). Complications included one malunion and one asymptomatic screw malposition. All patients attaining union were pleased with the procedure.

Management of acquired adult dropfoot.

Dropfoot is a catchall term for ankle equinus, equinovarus, and equinovalgus. The deformity can be flexible or rigid and may be associated with other pathology. In the adult, dropfoot may be congenital or acquired. Acquired dropfoot results from weakness of the ankle dorsiflexors, overpull of the plantarflexors, contracture of the soft tissues, bony deformity, or any combination of these factors. Appropriate treatment includes observation, orthotic devices, bracing, tendon transfers, arthrodesis, and neurolysis. The purpose of this paper is to review the pathophysiology and treatment of acquired dropfoot.

Acute lateral ankle ligament injuries: a literature review.

The average general orthopaedic surgeon examines and treats a considerable number of acute lateral ankle ligament sprains in a busy office practice. A cursory review of recent articles published on this subject will present a confusing picture regarding diagnosis and treatment of Grade III injuries. An air of controversy surrounds the interpretation of diagnostic x-rays, and the management of these common ankle problems. This review article is presented to summarize current thoughts on the anatomy, biomechanics, diagnosis, and treatment of acute lateral ankle ligament sprains.

An anatomic study of subtalar instability.

Subtalar instability has been recognized as a cause of ankle symptoms. The purpose of this anatomic study is to determine the ligament damage required to produce subtalar instability, and to define a radiographic technique to demonstrate it. Ten fresh adult cadaver ankles were dissected. Selective sectioning of the calcaneofibular ligament, capsule, and interosseous ligaments of the subtalar joint were done. Radiographic documentation of subtalar opening was recorded, using a lateral and Brodan's view. Sectioning of the calcaneofibular ligament alone produced a 5-mm opening of the subtalar joint. When combined with sectioning of the interosseous ligament, a 7-mm opening was produced. This was reproduced with a plantar flexion-supination load to the foot. Instability of the ankle joint (talar tilting) was produced only when loading caused additional tearing of the anterior talofibular ligament. This study suggests that surgical repairs to correct lateral ankle instability should include repair or substitution of the calcaneofibular ligament if subtalar instability is a consideration.

Lateral decompression for malunited os calcis fractures.

Nineteen heels in 19 patients underwent a lateral decompression for hindfoot pain secondary to a malunited os calcis fracture with subtalar intra-articular involvement. The operative procedure consisted of a lateral calcaneal bony prominence removal (ostectomy) and sural nerve release or transection. In addition, the peroneal tendons were released, relocated, and lengthened as necessary, with repair or reconstruction of their retinaculum. Eight patients (group I) had previously undergone a late subtalar fusion without relief of lateral symptoms. Eleven patients (group II) underwent a lateral decompression as an alternative to late subtalar fusion. In both groups combined, there were 14 males and 5 females with an average age of 40 years. The average follow-up was 28 months in group I and 17 months in group II. A satisfactory result was obtained in 75% (6 of 8) of the patients in group I and in 82% (9 of 11) of the patients in group II. This compares to a published success rate of approximately 50% in selected series in the literature and the authors' similar success rate of 46% for late subtalar fusion for the same pathology. The results suggest that the lateral decompression procedure offers a technically simpler yet effective alternative to late subtalar fusion for lateral pain following a malunited os calcis fracture with subtalar intra-articular involvement.

A modification of the Bristow procedure for recurrent anterior shoulder dislocation and subluxation.

A modification of the Bristow procedure for recurrent anterior shoulder dislocation and subluxation is presented. This report includes 20 shoulders in 20 patients available for adequate followup operated on by senior author from April 1976 to August 1981. The average follow-up period was 42.5 months (3.5 years). The average age at the time of surgery was 24.7 years. No recurrences were noted in the follow-up period. Complications related to screw fixation with Woodruff screws occurred early in the series in three patients (15%), but did not result in instability. Range of motion measurements postoperatively emphasized quantitation of external rotation at 90 degrees of abduction in the operated as compared to the nonoperated shoulder. The average loss of external rotation was 10.3 degrees. Excluding one poor result, this equated to an average loss of only 7.4 degrees. Fourteen of 16 operated dominant arms (87.5%) returned to throwing and overhead motion sports postoperatively. A description of the operative procedure and postoperative rehabilitation course is included. This modification emphasizes accurate and firm repair of the Bankart lesion under excellent operative exposure allowing institution of early range of motion exercises.

Acute shoulder dislocations: factors influencing diagnosis and treatment.

The Bankart lesion is the most important single causative factor in traumatic anterior shoulder dislocations (85%). Capsular rupture occurs in approximately 15% of traumatic anterior shoulder dislocations and may or may not heal with redundancy. If so, recurrent dislocation in possible. Surgical repair of traumatic anterior dislocations requires that the capsule be opened for correct identification of the lesion and correct repair. Limitation of external rotation is not necessary for repair of anterior shoulder dislocations and should be considered as an untoward complication. While multiple procedures are available, all of which may be satisfactory at one time or another, no one procedure repairs all traumatic anterior shoulder dislocations.