Anatomy of the Flexor Hallucis Longus and Its Relationship With Hallux Valgus: A Cadaveric Study.

BACKGROUND: Hallux valgus (HV) is a complex deformity, with many associated risk factors. The flexor hallucis longus (FHL) tendon is a dynamic and potentially deforming force as it bowstrings laterally with HV. We hypothesized that FHL is more laterally inserted in the distal phalanx in cadavers with HV; therefore, it might be also a primary destabilizing force. We aim to compare the FHL distal insertion morphology and its relationship with osseous structures in cadavers with and without HV. METHODS: Sixteen cadaver specimens, 8 with HV and 8 without (N-HV) were dissected. We evaluated FHL distal morphology in terms of its insertional footprint location and FHL long-axis position in relation to osseous anatomy. RESULTS: Both the HV and N-HV groups displayed a laterally inserted footprint at the distal phalanx, with the HV group exhibiting median lateral translation of the footprint 6% greater than the N-HV group (P < .01). Both groups also demonstrated a laterally displaced position for the FHL long axis. The median FHL long axis for HV vs N-HV specimens 1 cm proximal to the IP joint was 9% more laterally displaced from the midaxis (P < .01), and at 1 cm proximal to the MTP joint was measured to be 15% more laterally displaced from the midaxis (P < .01). CONCLUSION: FHL demonstrated an eccentric position in terms of insertion and trajectory in both the HV and N-HV groups, with greater lateralization in specimens exhibiting HV deformity. This eccentricity potentially creates a greater deforming force vector contributing to the development of HV. CLINICAL RELEVANCE: The etiology and progression of HV deformity may include a lateralized insertion of the FHL tendon. Treatment implications remain unknown at this time.

Short-term Results of Hemiarthroplasty of the Ankle Joint for Talar-Sided Cartilage Loss.

Background: Ankle hemiarthroplasty is a 1-piece implant system replacing the talar side of the tibiotalar joint. Hemiarthroplasty offers limited bone resection and may provide easier revision options than joint-ablating procedures. Methods: Prospective, multicenter, noncomparative, nonrandomized clinical study with short term follow-up on patients undergoing hemiarthroplasty of the ankle. Radiologic and functional outcomes (Foot and Ankle Outcome Score FAOS, Foot and Ankle Ability Measure [FAAM], Short Form-36 Health Survey [SF-36], Short Musculoskeletal Functional Assessment [SMFA], and visual analog scale [VAS] pain scores) were obtained at 3 and 12 months and the last follow-up (mean 31.9 months). Results: Ten patients met the inclusion criteria. Three were converted to total ankle replacement at 14, 16, and 18 months. Pain VAS scores improved on average from 6.8 to 4.8 (P = .044) of the remaining 7 at a mean of 31.9 months' follow-up. For these 7 in the Survival Group, we found that SF-36 physical health component improved from 25.03 to 42.25 (P = .030), SMFA dysfunction and bother indexes improved from 46.36 to 32.28 (P = .001), and from 55.21 to 30.14 (P = .002) in the Survival Group, and FAAM sports improved from 12.5 to 34.5 (P = .023). Conclusion: Patients undergoing hemiarthroplasty of the ankle joint for talar-sided lesions had a 30% failure rate by 18 months. Those who did not have an early failure exhibited modest pain reduction, functional improvements, and better quality of life in short-term follow-up. This procedure offers a possible alternative for isolated talar ankle cartilage cases. Level of Evidence: Level IV, prospective case series.

Tendones peroneos: una revisión contemporánea / Peroneal tendons. Contemporary update

La patología de peroneos es compleja y frecuentemente subdiagnosticada. El conocimiento detallado de la anatomía, biomecánica y fisiopatología es fundamental para realizar un correcto diagnóstico y tratamiento. El objetivo de este artículo es revisar la información más actualizada sobre la patología de los tendones peroneos (tendinopatía, inestabilidad y rotura).

Pathology of the peroneal tendons is complex and often underdiagnosed. Knowledge of anatomy, biomechanics, and physiopathology is necessary for diagnosing and treating this condition. The objective of this article is to review the most updated information regarding peroneal tendon pathology (tendinopathy, dislocation/subluxation, and tears), which may help managing patients with lateral pain of the foot and ankle.

One-Stage Lengthening and Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy (DMMO) for Brachymetatarsia.

Level of Evidence: Level V.

Large variation in management of talar osteochondral lesions among foot and ankle surgeons: results from an international survey.

PURPOSE: Surgeons management of osteochondral lesions of the talus (OLT) may be different to the published guidelines because not all treatment recommendations are feasible in every country. This study aimed to assess how OLT are managed worldwide by foot and ankle surgeons. METHODS: A web-based survey was distributed to the members of 21 local and international scientific societies focused on foot and ankle or sports medicine surgery. Answers with a prevalence greater than 75% of respondents were considered a "main tendency", whereas where prevalence exceeded 50% of respondents they were considered a "tendency". RESULTS: A total of 1804 surgeons from 79 different countries returned the survey. The responses to 19 of 28 questions (68%) regarding management and treatment of OLT achieved a main tendency (> 75%) or a tendency (> 50%). Symptoms reported to be most suspicious for OLT were pain on weight-bearing (WB) and after activity (83%), deep localization of the pain (62%), and any history of trauma (55%). 89% of surgeons routinely obtain an MRI, 72% routinely get WB radiographs, and 50% perform a CT scan. When treated surgically, OLTs are managed in isolation by only 7% of surgeons, and combined with ligament repair or reconstruction by 79%; 67% report simultaneous excision of soft-tissue or bony impingements (64%). For lesions less than 10-15 mm in diameter, bone marrow stimulation (BMS) represents the first choice of treatment for 78% of surgeons (main tendency). No other treatment was recorded as a tendency. For lesions greater than 15 mm in diameter no tendencies were recorded. The BMS represented the most preferred treatment being the first choice of treatment for 41% of surgeons. OLT depth had little influence on treatment choice: 71% of surgeons treating small lesions and 69% treating large lesions would choose the same treatment regardless of whether the lesion had a depth lesser or greater than 5 mm. CONCLUSION: The management of OLT by foot and ankle surgeons from around the world remains extremely varied. The main clinical relevance of this study is that it provides updated information with regard to the management of OLT internationally, which could be used by surgeons worldwide in their decision-making and to inform the patient about available surgical options. LEVEL OF EVIDENCE: Level IV.

Cross-cultural adaptation and validation of the Foot and Ankle Outcome Score (FAOS) into Spanish (Chile).

PURPOSE: To adapt and validate the English version of the Foot and Ankle Outcome Score (FAOS) into Spanish FAOS-CL, following the WHO guidelines. METHODS: A cross-sectional study including 318 outpatients with non-traumatic conditions. Validity, acceptability and internal consistency including correlations with the Medical Outcome Study Short Form 36 are reported. RESULTS: The preliminary version resulted from the forward and back-translation and a pilot administration. Validation response rate was 99.22%. Substantial ceiling effects were observed for Symptoms and ADL and floor effect for QoL sub-scales. The FAOS-CL had excellent internal consistency (Cronbach's α = 0.98). The principal component analysis gave five factors explaining the 72.6% of the variance. The FAOS-CL items significantly correlate with their sub-scales. FAOS-CL sub-scales significantly correlated with SF-36 components and subcomponents. CONCLUSION: The first Spanish version of the FAOS was generated. Culturally adapted and validated with high reliability capable of evaluating different foot and ankle conditions.

Knotless Modified Arthroscopic-Broström Technique for Ankle Instability.

Instability is a common sequela after repeated ankle sprains. When nonoperative treatment fails, open lateral ligament complex repair and reinforcement with the inferior extensor retinaculum has been the gold standard procedure. The recent advancements in arthroscopic techniques have created comparable biomechanical and functional results to open procedures. The authors' modification to the standard arthroscopic technique permits ligament approximation to the distal fibula over a larger surface area, using knotless anchors to avoid the need of an accessory portal and limit potential suture knot-related complications. Level of Evidence: Level V, expert opinion.

Technique tip: EDL-to-EHL double loop transfer for extensor hallucis longus reconstruction.

BACKGROUND: Extensor hallucis longus (EHL) tendon injuries often occur in the setting of lacerations to the dorsum of the foot. End-to-end repair is advocated in acute lacerations, or in chronic cases when the tendon edges are suitable for tension free repair. Reconstruction with allograft or autograft is advocated for cases not amenable to a primary direct repair. This is often seen in cases with tendon retraction and more commonly in the chronic setting. In many countries the use of allograft is very limited or unavailable making reconstruction with autograft and tendon transfers the primary choice of treatment. Tendon diameter mismatch and diminished resistance are common issues in other previously described tendon transfers. METHODS: We present the results of a new technique for reconstruction of non-reparable EHL lacerations in three patients using a dynamic double loop transfer of the extensor digitorum longus (EDL) of the second toe that addresses these issues. RESULTS: At one-year follow up, all patients recovered active/passive hallux extension with good functional (AOFAS Score) and satisfaction results. No reruptures or other complications were reported in this group of patients. No second toe deformities or dysfunction were reported. CONCLUSIONS: Second EDL-to-EHL Double Loop Transfer for Extensor Hallucis Longus reconstruction is a safe, reproducible and low-cost technique to address EHL ruptures when primary repair is not possible. LEVEL OF EVIDENCE: IV (Case Series).

Use of Three-dimensional Printing in Orthopaedic Surgical Planning.

BACKGROUND: Three-dimensional (3D) printing is a technique based on overlapping layers of a material (eg, plastic, clay, and metal). The widespread implementation of 3D printers has resulted in a notable increase in use. Fields such as construction, engineering, and medicine benefit from this technique. AIM: The use of 3D printed scale models permits better surgical planning and results. METHODS: The models were created based on CT images of seven patients (age range, 5 to 61 years) with different pathologies who were candidates for surgery. RESULTS: Surgical time decreased as a result of detailed surgical planning with printed models. This technique also was associated with a decrease in bleeding, a reduction in the amount of anesthesia required, and greater precision. In some patients, a change in surgical strategy was noted, thus allowing for a reduction in the number of surgeries and the aggressiveness of surgery. Finally, the preoperative practice (virtual and physical osteotomies using cutting tools) that was performed in two cases allowed the surgeon to evaluate the different approach alternatives and establish the best strategy. CONCLUSIONS: The use of 3D-printed anatomic models has improved surgical planning, especially for patients in whom the conventional techniques are insufficient for establishing a proper strategy. The extra information provided by 3D-printed models can lead to a better intervention strategy, which is beneficial for patients because it decreases the risks, procedure times, and recovery times.

Cement Casting to Optimize Reconstruction of Chronic Osteochondral Lesions of the Talus.

Few surgical techniques have been described for reconstruction in massive osteochondral lesions of the talus, and there is limited evidence of techniques for accurately reproducing native talar anatomy with bone auto/allograft techniques. In this article, we present a novel technique, which is highly reproducible, using bone cement to restore the congruence and anatomy of the ankle joint. LEVELS OF EVIDENCE: Level V: Technical tip.

Are locking plates better than non-locking plates for treating distal tibial fractures?

BACKGROUND: Locking and non-locking plates has been used for distal tibia fracture osteosynthesis. Sufficient evidence to favor one implant over the other is lacking in the current literature. Our aim is to compare them in terms of fracture healing, alignment, functional outcome, complications. METHODS: Sixty-eight patients operated on using a percutaneous plate were retrospectively reviewed. They were divided into two groups: in group 1 (28 patients) a 4.5mm narrow conventional dynamic compression plate (DCP) was used. In group 2 (40 patients) a titanium locked compression plate (LCP) was used. RESULTS: Mean time to union was 16.2 and 15.4 weeks for group 1 and 2, respectively (p=0.618). 11 patients (39.3%) in group 1 and 4 patients (10%) in group 2 showed malalignment (p=0.016). AOFAS scores at follow up were 89 and 88 in groups 1 and 2, respectively. Implant removal was necessary in 9 cases (32.1%) and 4 cases (10%) in group 1 and group 2, respectively (p=0.042). Three patients (10.7%) in group 1 and three patients (7.5%) in group 2 had an infection. CONCLUSIONS: Both plating systems have similar results in terms of time to union, infection, and AOFAS scores. The LCP seems superior with respect to alignment and the need for implant removal.

Continuous popliteal block for postoperative analgesia in total ankle arthroplasty.

BACKGROUND: Total ankle arthroplasty is associated with severe postoperative pain. Development of analgesic techniques such as a block with continuous infusion at the popliteal level has been shown to result in good pain control, a decrease in the use of rescue analgesia and a low rate of complications. We reviewed our experience with this method of analgesia in patients who underwent total ankle arthroplasty. METHODS: A prospective study of 30 patients undergoing total ankle arthroplasty was carried out. Twenty-two of these received and maintained a block at the popliteal level with a continuous infusion of bupivacaine, while the remaining eight received no such block. RESULTS: The visual analog scale evaluation (VAS) showed a significant improvement in pain control in the group with the popliteal block after 6, 12, 18, and 24 hours postsurgery, with pain levels peaking and being most different between 6 and 12 hours postsurgery for the two groups. The group with the popliteal block also exhibited a significantly lower consumption of morphine and a greater degree of patient satisfaction. CONCLUSION: The block with continuous infusion at the popliteal fossa was a safe technique for total ankle arthroplasty postoperative analgesia, which provided good pain control, a lower requirement of opiates and a higher level of patient satisfaction.

Is percutaneous repair better than open repair in acute Achilles tendon rupture?

BACKGROUND: Open repair of Achilles tendon rupture has been associated with higher levels of wound complications than those associated with percutaneous repair. However, some studies suggest there are higher rerupture rates and sural nerve injuries with percutaneous repair. QUESTIONS/PURPOSES: We compared the two types of repairs in terms of (1) function (muscle strength, ankle ROM, calf and ankle perimeter, single heel rise tests, and work return), (2) cosmesis (length scar, cosmetic appearance), and (3) complications. PATIENTS AND METHODS: We retrospectively reviewed 32 surgically treated patients with Achilles rupture: 17 with percutaneous repair and 15 with open repair. All patients followed a standardized rehabilitation protocol. The minimum followup was 6 months (mean, 18 months; range, 6-48 months). RESULTS: We observed similar values of plantar flexor strength, ROM, calf and ankle perimeter, and single heel raising test between the groups. Mean time to return to work was longer for patients who had open versus percutaneous repair (5.6 months versus 2.8 months). Mean scar length was greater in the open repair group (9.5 cm versus 2.9 cm). Cosmetic appearance was better in the percutaneous group. Two wound complications and one rerupture were found in the open repair group. One case of deep venous thrombosis occurred in the percutaneous repair group. All complications occurred before 6 months after surgery. We identified no patients with nerve injury. CONCLUSIONS: Percutaneous repair provides function similar to that achieved with open repair, with a better cosmetic appearance, a lower rate of wound complications, and no apparent increase in the risk of rerupture. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Longitudinal tears of peroneus longus and brevis tendons: a gouty infiltration.

The natural history of recurrent uric acid deposition includes joint destruction, as well as tendon weakening and rupture. Simultaneous rupture of the peroneus longus and brevis tendons secondary to tophaceous gout is very rare. In the present report, we describe the case of a 37-year-old man who had a history of recurrent ankle pain and 4 previous episodes of acute gout localized to his ipsilateral first metatarsophalangeal joint. The physical examination revealed the ankle pain to actually be localized to the peroneal tendons immediately distal to the fibular malleolar groove. Magnetic resonance imaging showed longitudinal tears in the peroneus longus and brevis. Surgical exploration and repair of the ruptured tendons revealed the presence of monosodium urate deposition within the substance of the tendons at the rupture sites. The tendons were debrided and repaired using longus to brevis tenodesis. The postoperative course was unremarkable and entailed referral to a rheumatologist for metabolic management. After more than a 1-year period of follow-up, the patient was ambulating without difficulties wearing regular shoe gear.