Isolated Gastrocnemius Recession for Progressive Collapsing Foot Deformity.

INTRODUCTION: Progressive collapsing foot deformity (PCFD) is frequently associated with a gastrocnemius contracture. Surgical treatment of PCFD often includes a gastrocnemius recession in addition to other corrective procedures, which typically requires a period of restricted weight bearing postoperatively. Isolated gastrocnemius recession may allow passive correction of the deformity, improve orthotic fit, and obviate the need for full reconstruction and restricted weight bearing. The goal of this study was to evaluate patient-reported outcomes after an isolated gastrocnemius recession for flexible PCFD in patients anticipated to have difficulty with postoperative restricted weight bearing. METHODS: A total of 47 patients met the inclusion criteria: isolated gastrocnemius recession for flexible PCFD, no previous ipsilateral surgery, and more than 6 months of follow-up. Of 47 eligible patients, 29 (31 feet) participated. Available preoperative and postoperative patient-reported outcomes were gathered, including the Foot and Ankle Ability Measure Activities of Daily Living, visual analog scale, and the Patient-Reported Outcome Measurement Information System Physical Function Short Form 10a. In addition, patients were asked about satisfaction, willingness to undergo the procedure again, and whether orthotics provided better relief. RESULTS: At a mean of 5.1 (range, 0.6 to 9.0) years postoperatively, median Foot and Ankle Ability Measure Activities of Daily Living was 82.1, mean Patient-Reported Outcome Measurement Information System Physical Function Short Form 10a was 44.2, and median visual analog scale was 10 (of 100). Sixty-nine percent of patients were either satisfied or very satisfied, 69% would undergo the procedure again, and 62% reported improved relief with use of orthotics postoperatively. Among the 47 eligible patients, there were 5 (11%) subsequent flatfoot reconstructions. CONCLUSIONS: Isolated gastrocnemius recession for the management of flexible PCFD can be effective as this procedure demonstrated good outcomes scores with high procedural satisfaction and 11% of patients proceeding to subsequent flatfoot reconstruction. This alternative approach may be of particular value for patients anticipated to have difficulty with postoperative weight-bearing restrictions. LEVEL OF EVIDENCE: :IV.

3-D generated anatomic custom talar cement spacers: case reports, technical tips and literature review.

BACKGROUND: With today's expanding use of total ankle arthroplasty, the ever-present trauma patient, and patients with uncontrolled comorbid conditions, surgeons face significant challenges for lower extremity reconstruction. These patients highlight some of those who may present with unique anatomy, bone loss, infection, and various other local and systemic factors that affect treatment options for successful outcomes. Three dimensional (3-D) printing for medical devices is allowing for new and customized ways to meet patient and surgeon goals of limb salvage and reconstruction. CASE PRESENTATIONS: While the majority of 3-D printing is done for the purpose of implantation, we present a technical tip for designing a 3-D printed mold from which to create an antibiotic cement spacer for implantation. With two case illustrations including a talus fracture nonunion and infected subtalar arthrodesis nonunion, we describe the process of patient selection, implant design, fabrication, and implantation of a custom molded antibiotic cement talus. DISCUSSION: Case illustrations present two successful limb salvage patients while giving a thorough explanation of our technique, learned tips and tricks. This applied technology builds on prior use of antibiotic cement in limb salvage of the lower extremity, most of which are joint sacrificing. 3-D printing the mold for an anatomic talus cement spacer results in a joint sparing limb salvage solution. Innovative 3-D printing technology is merged with current, pertinent literature regarding antibiotic cement to offer surgeons expanded options for temporary or definitive reconstructive techniques in some of the most challenging patients.

Effect of Muscle Activation on the Gravity Stress View in Unstable Weber B Ankle Fractures.

BACKGROUND: In the setting of apparently isolated distal fibula fractures, the gravity stress view (GSV) is a validated method to determine mortise stability. There is currently no published data evaluating whether dynamic muscle activation can reduce an unstable mortise. If patients with instability can overcome gravity, resultant images could yield false-negative results. The goal of this investigation was to determine if patient effort can influence medial clear space (MCS) measurements in proven unstable bimalleolar-equivalent ankle fractures. METHODS: Patients presenting with Weber B fibula fractures were assessed for mortise stability using the GSV. If the GSV demonstrated instability based on MCS widening >4 mm, 3 additional views were performed: GSV with an assistant maintaining the ankle in a neutral position; GSV with the patient actively dorsiflexing to neutral; and GSV with the patient actively dorsiflexing and supinating the foot. Twenty-four consecutive patients met inclusion criteria, with a mean age of 48.7 (range, 22-85) years. Fifteen patients (62.5%) were female and 9 (37.5%) were male. The laterality was evenly divided. RESULTS: The mean MCS was 5.8 ± 2.0 6.0 ± 2.6, and 6.2 ± 2.7 mm for the manual assist, active dorsiflexion, and active supination radiograph measurement groups, respectively (P = .434). Only 5 of 24 subjects had any measurable decrease in their MCS with active supination, with a maximum change of 1.2 mm. The remainder of the patients had an increase in MCS ranging from 0.1 to 4.0 mm. CONCLUSION: There was no significant difference between measurement states indicating that muscle activation is unlikely to yield a false-negative result on GSV. Mortise instability, secondary to deep deltoid injury in the presence of gravity stress, is unlikely to be actively overcome by dynamic stabilizers, supporting the validity and specificity of the GSV. LEVEL OF EVIDENCE: Level III, prospective study.

Arthrofibrosis of the Ankle.

Arthrofibrosis is a common, but often overlooked, condition that imparts significant morbidity following injuries and surgery to the foot and ankle. The most common etiologies are related to soft tissue trauma with subsequent fibrotic and contractile scar tissue formation within the ligaments and capsule of the ankle. This leads to pain, alterations in gait, and ankle dysfunction. Initial treatment often includes extensive physical therapy, however, if severe enough surgical options exist. Although the literature regarding ankle arthrofibrosis is scarce, this review article provides a greater understanding of the pathogenesis of arthrofibrosis and describes the current and future therapeutic options to treat fibrotic joints. Level of Evidence: Level V, expert opinion.

Radioulnar space available at the level of the biceps tuberosity for repaired biceps tendon: a comparison of 4 techniques.

HYPOTHESIS: It is unknown whether certain methods of distal biceps tendon repair lead to an increased propensity of impingement of the repaired tendon. The purpose of this study was to evaluate various repair techniques in a cadaveric model to determine the radioulnar space available for the repaired biceps tendons. METHODS: Nine matched pairs of quartered, fresh-frozen cadaveric arms were transected at the level of the humeral mid shaft and the distal radiocarpal joint. Distance measurements and the angular relation of the bicipital tuberosity were measured at 5 forearm pronation-supination positions. These measurements were taken under each of the following conditions: intact native biceps, resected native tendon, suture anchor fixation of the biceps, suspensory suture device fixation of the biceps, tendon repair using a tenodesis technique, and fixation of the tendon using a trough technique. RESULTS: There were no significant differences in radioulnar space available after biceps tendon repair with the forearm in a supinated position. However, when the forearm was in a neutral or pronated position, the suture anchor method consistently had the lowest biceps insertion-to-ulna distance (0.6 to 2.1 cm). All forearm positions, except full supination, showed significant differences in terms of radioulnar space available for the repaired biceps. DISCUSSION: This study shows that the space available for the biceps tendon decreases with forearm pronation after reconstruction for all repair techniques. It appears that using suture anchors to repair the biceps tendon may predispose the repaired tendon to impingement when compared with other fixation techniques.