Anterior Ankle Incision Healing Complications With and Without Tourniquet Use: A Retrospective Comparative Cohort Study.

Anterior ankle incisions and tourniquet use in foot and ankle surgery have both been associated with increased incidence of incisional healing complications. Although a tourniquet is commonly used for procedures such as total ankle replacement and ankle arthrodesis that utilize an anterior ankle incision, it is possible to avoid tourniquet use while preserving adequate visualization with atraumatic layered dissection and closure, appropriate use of electrocautery, and ligation of vessels as needed. The primary aim of this study is to report rates of anterior ankle incisional healing complications both with and without tourniquet use. A retrospective chart review was performed on consecutive patients undergoing total ankle replacement or ankle arthrodesis through a multi-provider foot and ankle surgery practice between 2013 and 2018. A total of 121 patients, 58 (47.9%) in the tourniquet group and 63 (52.1%) in the no-tourniquet group, were included in this study with a median follow-up period of 36 (range 2-96) months. There was a higher rate of incisional healing complications for the tourniquet group (5.2%) compared to the no-tourniquet group (3.2%), however this did not reach statistical significance (p = .670). There was no significant difference in operative time between the tourniquet and no-tourniquet group (p = .405). The overall incisional healing complication rate was 4.1%. Although avoiding tourniquet use alone does not appear to significantly reduce anterior ankle incisional healing complications, the described technique has yielded an overall lower rate of incisional complications compared to those commonly reported in the literature.

Tibiotalocalcaneal Arthrodesis with Structural Allograft for Management of Large Osseous Defects of the Hindfoot and Ankle: A Systematic Review and Meta-Analysis.

Large osseous defects of the hindfoot and ankle pose a surgical challenge. Tibiotalocalcaneal (TTC) arthrodesis utilizing a structural allograft may be required to fill the osseous void, preserve limb length and achieve fusion. Several authors have reported small case series on this topic, however outcomes have varied and no systematic review of this data has been published to date. The primary aim of this study is to report rates of osseous union, limb salvage and complications in patients undergoing TTC arthrodesis with a structural allograft. A total of 11 publications were identified that met the inclusion criteria. One hundred seventy-five patients were included with a weighted mean age of 60.5 (range 50-72) years and follow-up period of 29.7 (range 3-62) months. Femoral head allograft was the most commonly utilized structural graft and a retrograde intramedullary nail was the most common fixation construct. Results demonstrated an overall union rate of 67.4%, limb salvage rate of 92.5% and complication rate of 26.6%. Allograft-related complications were rare with an allograft fracture rate of 0.1% and allograft collapse rate of 1.2%. There was no significant difference in union rate when using a retrograde intramedullary nail versus a plate construct (p = .9148). TTC arthrodesis with use of a structural allograft is a viable treatment option for limb salvage when faced with complex hindfoot and ankle pathology involving large osseous defects. Despite high rates of radiographic nonunion, this approach can provide patients with a stable and functional limb while avoiding amputation.

Progression of Healing on Serial Radiographs Following First Ray Arthrodesis in the Foot Using a Biplanar Plating Technique Without Compression.

A review of 195 first ray arthrodeses fixated with a twin-plate biplanar construct, without interfragmentary compression, is presented. This fixation construct was evaluated in a consecutive cohort of patients undergoing first metatarsophalangeal joint (MTP) arthrodesis or the first tarsometatarsal joint (TMT) arthrodesis. Multiple radiographs were used to assess the progression of healing at the following postoperative time frames: 4 to 9 weeks, 10 to 12 weeks, >12 weeks, and the final follow-up. In total, 85 feet underwent first MTP arthrodesis, and 110 feet underwent first TMT arthrodesis. At the final radiographic follow-up, 97.44% of all cases had shown progressive osseous gap filling at the arthrodesis site, stable position of the bone segments, and intact hardware without loosening, 98.24% of the first MTP arthrodesis group and 96.82% of the first TMT arthrodesis group. Five (5.43%) feet had the presence of lucency at the fusion interface at the final follow-up, without positional change or hardware failure. Four (1.8%) feet had a failure of the hardware, loss of position, or frank gapping at the fusion site. Lucency decreased consistently over time in this series of patients (p < .00001). Progressive increase in callus density at the fusion site on serial radiographs was noted to be a consistent finding for both procedures and was the primary indicator of secondary bone healing at the noncompressed, relatively stable arthrodesis site. Our results confirm that biplanar plating construct without interfragmentary compression produces high fusion rates following the first MTP or TMT arthrodesis, with early weightbearing.

Comparison of Transverse and Coronal Plane Stability at the First Tarsal-Metatarsal Joint With Multiple Screw Orientations.

Intercuneiform instability has been recognized as a potential cause of hallux valgus recurrence following tarsal-metatarsal joint (TMTJ) fusion. Recommendations have been made for additional screw placement between the metatarsals and/or the cuneiforms to improve stability. The screw orientation that provides the best stability has not been documented. Twelve cadavers with the first TMTJ fixated were used for testing. Using a consistent force application of 15 pounds in both the transverse and coronal planes, we measured the change in intermetatarsal angle on radiographs. Force testing was repeated with screws deployed individually in the following orientations: first to second cuneiform (CC), first to second metatarsal (MM), and first metatarsal to middle cuneiform (MC). Our results indicate that stability of the first ray in the transverse and coronal planes is not improved with TMTJ fixation alone or with an additional CC screw. The MM screw consistently reduced first metatarsal instability in both planes. The MC screw had intermediate results. These findings strengthen the notion that first ray instability is complex and involves the tarsal and metatarsal articulations at multiple levels outside of the TMTJ alone. LEVELS OF EVIDENCE: Diagnostic and Therapeutic, Level IV: Cadaveric Study.