The Medial Gastrocnemius Recession, an Alternative Surgical Treatment for Isolated Gastrocnemius Contracture: A Cadaver Study With Discussion Emphasizing Variable Conjoint Tendon Anatomy.

BACKGROUND: Gastrocnemius recession is a popular procedure utilized to treat chronic conditions related to isolated gastrocnemius contracture (IGC). Recent anatomical research detailing variable gastrocsoleus tendon morphology has raised important questions regarding the safety of some traditional recession procedures. Alternative gastrocnemius recession strategies may produce comparable dorsiflexion improvement results while avoiding the surgical risk related to conjoint tendon anatomical variability. METHODS: Ten matched cadaver pairs were randomized to receive either a medial gastrocnemius recession (MGR) procedure or a gastrocnemius intramuscular recession "Baumann" procedure. Postoperative dorsiflexion improvement was measured and then compared between groups. Detailed postoperative surgical dissections were performed to assess structures at risk, conjoint tendon morphology, and anatomical symmetry. RESULTS: Medial gastrocnemius recession and Baumann procedures were equally effective at producing significant increases in passive ankle dorsiflexion. No sural nerve injuries were observed. Thirty-five percent of specimens showed direct muscular fusion of at least a portion of the distal gastrocnemius muscular tissue to the adjacent soleus. CONCLUSION: The MGR procedure produced comparable dorsiflexion improvement results to the Baumann procedure in our cadaver model. Surgeons must account for certain conjoint tendon anatomical variants when surgically treating IGC as traditional recession methods risk tendo-Achilles overlengthening. LEVELS OF EVIDENCE: Level V: Cadaver Study.

Does Functional Neuromuscular Electrical Stimulation (NMES) Influence Calf Atrophy Following Achilles Tendon Surgery? Prospective Double-Blind Randomized Controlled Trial on the Use of Immediate Postoperative Electrical Muscle Stimulation to Preserve Muscle Function and Volume.

Surgical repair of the Achilles tendon can lead to prolonged calf atrophy and functional limitations, even with early weightbearing. The use of neuromuscular electrical stimulation (NMES) has been studied in muscle rehabilitation programs following anterior cruciate ligament repair. Accelerated recovery and pain reduction were noted. The aim of the present study was to evaluate the use of electrical stimulation on maintaining calf muscle cross-sectional area volume and improving patient reported outcome measures following Achilles tendon surgery. Randomized controlled clinical trial. Forty patients were enrolled. All patients had undergone repair of the Achilles tendon. A 4 lead NMES device was applied at time of surgery with both patient and surgeon blinded to activity of the device. All patients followed a standardized postoperative protocol. Group 1 consisted of 20 patients who received protocol specific NMES. Group 2 was the "sham device" control group, receiving subtherapeutic electrical stimulation. Preoperative and postoperative calf circumference (2, 6, 12 weeks) and magnetic resonance imaging (MRI) scans (2, 6 weeks) were conducted. Patient-reported functional outcome scores were measured. Of the 40 patients, 23 (57.5%) were male and 17 (42.5%) were female. The mean age was 48.9 years (11.1 standard deviation [SD]) with a mean body mass index of 32.2 kg/m2 (5.7 SD). Calf measurements for Group 1 (39.3 cm and 39.7 cm) were slightly higher compared Group 2 (38.4 cm and 39.2 cm) at 6 and 12 weeks postoperative. Functional scores were similar between Groups 1 and 2 at final follow-up. Foot/Ankle Computer Adaptive Test scores were 55.1 (6.9 SD) versus 58.4(8.6 SD), and American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scores were 82.3 (8.2 SD) and 83.9 (9.3 SD), respectively. The visual analog scale at 12-week visit for Groups 1 and 2 was 8.4 (9.3 SD) and 8.4 (9.1 SD), respectively. This prospective randomized controlled trial was undertaken to quantify and validate the effect and ability of NMES to minimize calf atrophy after acute or chronic repair. No statistically significant difference was found between active NMES and sham control group. There was a trend showing some maintenance of calf volume per MRI study.

Surgical Treatment of Subtalar Joint Instability: Safety and Accuracy of a New Technique in a Cadaver Model.

New surgical strategies to treat symptomatic subtalar joint (STJ) instability are evolving. We modified a previously described reconstruction strategy and then refined our new surgical technique through simulated surgery and subsequent cadaver dissections. Our purpose was to show that a tunnel intended to facilitate STJ stabilization surgery could safely be drilled across the footprints of the interosseous talocalcaneal ligament (ITCL). A percutaneous fluoroscopically guided tunnel for the purpose of ITCL reconstruction was created in 10 cadaveric below-knee specimens. Accuracy of the tunnel with relation to the anatomic boundaries of the ITCL attachment sites as well as damage to relevant structures at risk were recorded. Two sets of 5 surgeries were performed to assess for improvement in technique. Mean distances from the tunnel to the ITCL on the calcaneus improved between groups 1 and 2: 4.04 and 1.80 mm, respectively (p = .04). Mean distances from the tunnel to the ITCL on the talus improved between groups 1 and 2: 6.2 and 1.8 mm, respectively (p = .08). With information obtained from this study, an osseous tunnel can be safely placed within 2 mm of the ITCL footprints.

A Comparison of Talar Surface Area Occupied by 2- Versus 3-Screw Fixation for Ankle Arthrodesis.

Background. Ankle arthrodesis is a procedure utilized in the treatment of end-stage ankle arthritis. Internal fixation with screws is traditionally relied on to achieve union. Although the use of screw fixation alone has produced satisfactory outcomes, nonunion rates can range from 9% to as high as 35%. Adding an additional screw to the traditional 2-screw fixation construct may improve the likelihood of union by adding strength and stiffness; however, this addition may counteract the theoretical fusion enhancement benefit by reducing the joint surface area (SA) available for fusion. Methods. A cadaver study was performed to compare the amount of SA lost from a standard 2-screw (group 1) versus the 3-screw ankle fusion construct (group 2). A total of 10 fresh cadaveric below-knee specimens were used. Cannulated 7.0-mm partially threaded screws were placed across the ankle joint. Each talus was examined to precisely determine joint SA loss following each procedure. Results. The mean total talus SA in group 1 was 1833.71 mm2 compared with 2125.76 mm2 in group 2. The mean SA lost by the 2-screw construct was 5.91%, versus 9.51% in the 3-screw construct group. The talus SA loss percentage difference between groups reached statistical significance (P = .0220). Conclusion. The addition of a third 7.0-mm screw to a 2-screw ankle fusion construct raised the percentage of joint surface lost from 5.91% to 9.5%. Clinical Relevance. Surgeons may consider using extra-articular plates with 1 or 2 intra-articular screws instead of the traditional 3-screw construct if there is an elevated concern for nonunion. Levels of Evidence: Level IV: Cadaveric case series.

Minimally Invasive Retrograde Method of Harvesting the Flexor Hallucis Longus Tendon: A Cadaveric Study.

BACKGROUND: Use of the flexor hallucis longus (FHL) tendon is well described for several tendon augmentation procedures. Harvesting the FHL through an open medial approach is commonly done, but is associated with anatomic risks. Recently, several authors have described a minimally invasive (MI) technique to harvest the FHL tendon utilizing a hamstring tendon stripper commonly used in ACL reconstruction. The purpose of this study was to evaluate the safety and effectiveness of harvesting the FHL tendon using this novel minimally invasive retrograde approach. METHODS: The FHL tendon was harvested through a transverse plantar incision over the interphalangeal joint of the great toe in 10 fresh-frozen cadaver lower extremities. A lateral-based incision for peroneal tendon repair was made and the FHL was retrieved. Tendon length, complications, and interconnections between the FHL and flexor digitorum longus (FDL) were recorded and classified. The specimens were then dissected by a single surgeon in a standardized fashion, and damage to any surrounding structures was recorded. RESULTS: The average length of the FHL tendon from the distal stump to the first intertendinous connection was 13.3 cm (range 8.8-16 cm, SD 2.3 cm). Eight cadavers demonstrated Plaass type 1 interconnections whereas 2 demonstrated type 3. There was no injury to the medial and lateral plantar arteries and nerves, plantar plate, or FDL tendons. One FHL tendon was amputated at the level of the sustentaculum during graft harvest. No injury of the medial neurovascular structures occurred with retrieval of the FHL tendon through the lateral incision. CONCLUSIONS: We found that care must be taken when approaching the sustentaculum with the tendon harvester in order to avoid amputation of the graft against a hard bony endpoint. Additionally, flexion and extension of the lesser toes could aid in successful tendon harvest when tendon interconnections were encountered. CLINICAL RELEVANCE: Using this MI technique appears to be a safe and effective way to obtain a long FHL tendon graft for tissue augmentation.

New Fixation Methods for the Treatment of the Diabetic Foot: Beaming, External Fixation, and Beyond.

Surgical correction of complex foot and ankle deformities secondary to Charcot neuroarthropathy remains a significant surgical challenge. New technological advancements in hardware have allowed for the use of augmented fixation techniques in midfoot deformity correction, including the use of indication-specific locking plates and beaming techniques that offer enhanced stability. Severe hindfoot deformity management can employ the use of internal fixation, including intramedullary hindfoot nails and circular external fixation frames for limb salvage.

Radiographic Assessment of a Medullary Total Ankle Prosthesis: A Test of Agreement and Reliability.

Total ankle replacement (TAR) is a viable alternative to ankle fusion in certain patients with end-stage ankle arthritis. Despite the importance of understanding alignment and movement of the prosthesis, there is no standardized radiographic method for evaluating the position and movement of the INBONE 2 prosthesis. The aims of this study were to describe a radiographic measurement protocol for INBONE 2 for clinical practice and research while determining the interobserver and intraobserver reliability using standard weightbearing radiographs. Fifteen patients were randomly selected with operative dates from January 2011 to January 2014 who underwent primary TAR using the INBONE 2 prosthesis. Most recent preoperative and first postoperative weightbearing anteroposterior and lateral radiographs were pulled and deidentified. Three foot and ankle surgeons blinded from the patient selection and deidentification, measured the described measurements on separate occasions. Intraobserver reliability: surgeon 1 had acceptable reliability for 9 of 13 continuous radiographic measurements (69.2%), surgeon 2 had acceptable reliability for 8 of 13 measurements (61.5%), and surgeon 3 had acceptable reliability for 12 of 13 measurements (92.3%). Interobserver reliability: among the first measurements, 6 of 13 continuous radiographic measurements (46.2%) had acceptable reliability. Among the second measurements, 7 of 13 measurements (53.8%) had acceptable reliability. Among the first and second measurements combined, 7 of 13 measurements (53.8%) had acceptable reliability. This study promotes the need for meticulous evaluation of annual radiographic findings following TAR in an effort to avoid catastrophic failure and represents moderate agreement can be obtained by employing the proposed measurements for surveillance of INBONE 2 TAR at annual postoperative visits. Measurements on the anteroposterior radiograph appear to demonstrate more consistent results for surveillance than lateral measurements. The intraobserver reliability results were somewhat superior to the interobserver reliability, implying more relevance for a single surgeon applying these measurements annually for postoperative surveillance. LEVELS OF EVIDENCE: Diagnostic, Level III.

Rate of Malunion Following Bi-plane Chevron Medial Malleolar Osteotomy.

BACKGROUND: Access to the medial half of the talus can be challenging even with an osteotomy. Although several techniques are presented in the literature, critical evaluation of fixation, union, and alignment is lacking. The chevron medial malleolar osteotomy provides advantages of perpendicular instrumentation access and wide exposure to the medial talus. Postoperative displacement resulting in malunion, and possibly provoking ankle osteoarthritis, is a known complication. The present study describes our experience with the osteotomy. METHODS: A consecutive series cohort of 50 bi-plane chevron osteotomies performed from 2004 to 2013 were evaluated. Forty-six were secured using 2 lag screws, and 4 were secured using 2 lag screws and a medial buttress plate. Radiographic studies performed at 2, 6, and 12 weeks and at final follow-up were analyzed for postoperative displacement, malunion, non-union, and hardware-related complications. RESULTS: At initial postoperative follow-up, 47 of 50 had adequate radiographs for review, and 18 of 47 (38.3%) showed some displacement when compared to the initial osteotomy fixation position. By final follow-up, 15 of 50 (30.0%) had measurable incongruence. Hardware removal was performed in 13 (26.0%) cases at an average of 2.4 years postoperation. CONCLUSION: Bi-plane medial malleolar chevron osteotomy fixed with 2 lag screws showed a 30.0% malunion rate with an average of 2 mm of incongruence on final follow-up radiographs, which is higher than what has been reported in the literature. In our practice, we now use a buttress plate and more recently have eliminated postoperative osteotomy displacement. LEVEL OF EVIDENCE: Level IV, retrospective case series.