Midfoot Trauma: Let's Get It Right the First Time.

Lisfranc injuries represent a wide variety of injury patterns, from stable midfoot sprains to grossly displaced fractures and fracture-dislocations. Obtaining and maintaining an anatomic reduction is critical in the treatment of these injuries. Considerable controversy remains as to the optimal method of treatment. Beyond the type and severity of the injury pattern, treatment decisions may ultimately be defined by activity-specific criteria and patient demographics.

Prevention of Avascular Necrosis with Fractures of the Talar Neck.

Displaced talar neck fractures no longer constitute a surgical emergency; timing of definitive surgery has no bearing on the risk of osteonecrosis. Amount of initial fracture displacement is best predictor of osteonecrosis. Grossly displaced fractures or fracture-dislocations should be provisionally reduced, with or without temporary external fixation. Periosteal stripping should be limited to only that necessary to obtain anatomic reduction. Dissection within the sinus tarsi or tarsal canal should be avoided. Rigid internal fixation with solid cortical screws countersunk within the talar head and placed below the "equator" of the talar head is imperative for optimum stability.

Revision Open Reduction and Internal Fixation of Ankle and Syndesmosis Malunions.

Malreduction of the fibula and syndesmosis remains a common complication associated with the surgical management of ankle fractures. This malreduction leads to profound alterations in the biomechanics of the ankle, leading to chronic pain and premature degenerative changes of the ankle. It is possible to correct many fibular and syndesmotic malunions with reconstructive surgical techniques, of which there are several for revising and salvaging the malreduced ankle mortise and tibiofibular syndesmosis.

Lisfranc injuries.

PURPOSE OF REVIEW: The purpose of this review is to discuss key anatomic and pathoanatomic factors, treatment principles, and patient outcomes of Lisfranc injuries. RECENT FINDINGS: Although open reduction and internal fixation (ORIF) remains the current gold standard of treatment, ORIF with primary arthrodesis has become increasingly popular in recent years, both for pure ligamentous and for bony-ligamentous injuries. Return to activity and competitive sports as well as overall patient outcomes have been further defined, suggesting that most patients are able to return to near pre-injury level if properly diagnosed and appropriately treated. Considerable controversy remains as to the optimal method of treatment of Lisfranc injuries and may ultimately be defined by activity-specific or sport-specific criteria.

Managing Complications of Calcaneus Fractures.

Calcaneus fractures remain among the most complicated fractures for orthopedic surgeons to manage because of the complexity of various fracture patterns, the limited surrounding soft tissue envelope, and the prolonged rehabilitation issues impacting function after successful treatment. Despite this, appropriate management of complications associated with calcaneus fractures is critical for the complete care of this injury, whether treated operatively or nonoperatively. The authors present the common complications encountered with fractures of the calcaneus and management thereof.

Salvage of failed total ankle arthroplasty with fusion using structural allograft and internal fixation.

BACKGROUND: The current study presents our experience with conversion of failed TAA to fusion. MATERIALS AND METHODS: A retrospective review of all failed total ankles converted to fusion from 1999 to 2009 was performed at our institution. RESULTS: Twelve total ankles were converted to isolated ankle fusions (Group I) and 12 converted to ankle-hindfoot fusions (Group II). All isolated ankle fusions were stabilized with anterior plate and screws with one nonunion. Structural bone graft was used in ten of 12. Mean outcome scores using the AOFAS-Ankle/Hindfoot score and Maryland Foot Score improved from preoperative values of 43 ± 13 and 56.7 ± 14 to 67 ± 12 and 71.2 ± 16 postoperatively, respectively (p < 0.05). All Group II ankle-hindfoot fusion patients were fixed using either anterior plate and screws, intramedullary nail, or a combination nail:plate construct. All received structural allografts. Five patients developed nonunion including four subtalar nonunions Preoperative scores on the AOFAS-AHS and MFS were 48.8 ± 14 and 58.3 ± 14. Postoperative scores were 51.2 ± 17 for the AOFAS and 64.5 ± 14 for the MFS. These changes were not statistically significant. However, the difference in nonunions was significant, p < 0.05. CONCLUSION: Failed total ankles can be successfully converted to fusion using structural bone graft and internal fixation. The primary risk appears to be nonunion of the subtalar joint when ankle-hindfoot fusion is required. We believe this risk can be decreased by using a separate approach for preparation of the subtalar joint.

The anatomic compression arthrodesis technique with anterior plate augmentation for ankle arthrodesis.

The anatomic compression arthrodesis technique with anterior plate augmentation is an effective technique that results in a high union rate, improved functional outcome, and an acceptable complication rate. This technique can be used for both primary ankle arthrodesis and salvage cases with significant bone loss. The authors believe the anterior plate is a useful complement to standard multiplanar screw fixation, and the increased rigidity provided by the anterior plate effectively counters forces, particularly in the sagittal plane, that may otherwise lead to failure of multiplanar screw constructs.

Subtalar fusion after displaced intra-articular calcaneal fractures: does initial operative treatment matter? Surgical technique.

BACKGROUND: Many patients with displaced intra-articular calcaneal fractures require subtalar arthrodesis for the treatment of posttraumatic arthritis. We hypothesized that patients who underwent initial operative treatment would have better functional outcomes as compared with those who underwent initial nonoperative treatment before undergoing a subtalar arthrodesis. METHODS: A consecutive series of sixty-nine patients with seventy-five displaced intra-articular calcaneal fractures underwent subtalar arthrodesis for the treatment of painful posttraumatic subtalar arthritis. Group A comprised thirty-four patients (thirty-six fractures) who initially were managed with open reduction and internal fixation and subsequently underwent in situ subtalar fusion at an average of 22.6 months later. Group B comprised thirty-five patients (thirty-nine fractures) who initially were managed nonoperatively and had development of a symptomatic painful malunion and subsequently underwent a subtalar distraction arthrodesis. The two groups were similar with respect to age, sex, injury mechanism, and smoking status. All complications were noted and functional outcomes were assessed at a minimum of forty-eight months after fusion. RESULTS: All sixty-nine patients were available for follow-up. The average duration of follow-up was 62.5 months for Group A and 63.5 months for Group B. There were three nonunions of the subtalar fusion requiring revision in each group. Group A had fewer postoperative wound complications and had significantly higher Maryland Foot Scores (90.8 compared with 79.1; p < 0.0001) and American Orthopaedic Foot and Ankle Society ankle-hindfoot scores (87.1 compared with 73.8; p < 0.0001) than did Group B. CONCLUSIONS: In our study population, better functional outcomes and fewer wound complications were associated with subtalar fusion for the treatment of symptomatic posttraumatic subtalar arthritis after initial open reduction and internal fixation of a displaced intra-articular calcaneal fracture as compared with subtalar arthrodesis for the treatment of symptomatic posttraumatic subtalar arthritis secondary to calcaneal malunion following initial nonoperative treatment.Initial open reduction and internal fixation restores calcaneal shape, alignment, and height, which facilitates the fusion procedure and establishes an opportunity to create a better long-term functional result. We recommend open reduction and internal fixation for the treatment of displaced intra-articular calcaneal fractures when appropriately indicated.

Subtalar fusion after displaced intra-articular calcaneal fractures: does initial operative treatment matter?

BACKGROUND: Many patients with displaced intra-articular calcaneal fractures require subtalar arthrodesis for the treatment of posttraumatic arthritis. We hypothesized that patients who underwent initial operative treatment would have better functional outcomes as compared with those who underwent initial nonoperative treatment before undergoing a subtalar arthrodesis. METHODS: A consecutive series of sixty-nine patients with seventy-five displaced intra-articular calcaneal fractures underwent subtalar arthrodesis for the treatment of painful posttraumatic subtalar arthritis. Group A comprised thirty-four patients (thirty-six fractures) who initially were managed with open reduction and internal fixation and subsequently underwent in situ subtalar fusion at an average of 22.6 months later. Group B comprised thirty-five patients (thirty-nine fractures) who initially were managed nonoperatively and had development of a symptomatic painful malunion and subsequently underwent a subtalar distraction arthrodesis. The two groups were similar with respect to age, sex, injury mechanism, and smoking status. All complications were noted and functional outcomes were assessed at a minimum of forty-eight months after fusion. RESULTS: All sixty-nine patients were available for follow-up. The average duration of follow-up was 62.5 months for Group A and 63.5 months for Group B. There were three nonunions of the subtalar fusion requiring revision in each group. Group A had fewer postoperative wound complications and had significantly higher Maryland Foot Scores (90.8 compared with 79.1; p < 0.0001) and American Orthopaedic Foot and Ankle Society ankle-hindfoot scores (87.1 compared with 73.8; p < 0.0001) than did Group B. CONCLUSIONS: In our study population, better functional outcomes and fewer wound complications were associated with subtalar fusion for the treatment of symptomatic posttraumatic subtalar arthritis after initial open reduction and internal fixation of a displaced intra-articular calcaneal fracture as compared with subtalar arthrodesis for the treatment of symptomatic posttraumatic subtalar arthritis secondary to calcaneal malunion following initial nonoperative treatment. Initial open reduction and internal fixation restores calcaneal shape, alignment, and height, which facilitates the fusion procedure and establishes an opportunity to create a better long-term functional result. We recommend open reduction and internal fixation for the treatment of displaced intra-articular calcaneal fractures when appropriately indicated.

A rational approach to ankle fractures.

Ankle fractures involve a spectrum of injury patterns from simple to complex, such that these injuries are not always "just an ankle fracture." By combining the injury mechanism and the radiographic findings, the surgeon can apply the Lauge-Hansen classification in taking a rational approach to the management of these fractures. Syndesmotic instability and atypical patterns are becoming increasingly recognized, in part through the judicious use of CT scans. The goal of surgical stabilization includes atraumatic soft tissue management, rigid internal fixation, and early range of motion exercises in maximizing return of function.

Management of intra-articular fractures of the calcaneus.

The treatment of calcaneal fractures has evolved over time. Despite understanding the pathomechanics involved, these fractures remain difficult to treat. Advances in imaging and surgical technology have enabled experienced fracture surgeons to obtain consistent results. Obtaining anatomic reduction at the time of surgery is not paramount importance. Minimally invasive approaches and the emergence of new technology may aid surgeons who treat these complex fractures.

Posttraumatic avascular necrosis of the talus.

Avascular necrosis of the talus is one the most challenging problems encountered in posttraumatic reconstruction of the hindfoot. Since the first description of the talus injury in 1608 by Fabricius of Hilden, our knowledge of the talar anatomy, injuries, sequelae, and management has increased significantly. Adequate knowledge of the etiology, the extent of the disease, and the degree of patient symptoms are required to determine optimal treatment.

Anterior plate supplementation increases ankle arthrodesis construct rigidity.

BACKGROUND: The success of ankle arthrodesis for the treatment of post-traumatic ankle arthritis depends on achieving and maintaining rigid fixation of the prepared tibiotalar interface. The purpose of this study was to examine the biomechanical effect of anterior plate supplementation of a popular three-screw fusion construct. METHODS: Six fresh-frozen cadaver ankles were prepared and instrumented with three partially threaded screws compressing the tibiotalar interface. Testing was done with and without supplementary anterior plate fixation under three different decoupled loading conditions: plantarflexion/dorsiflexion, inversion/eversion, and rotation. Motion at the tibiotalar interface was recorded. RESULTS: Anterior plating increased construct stiffness by a factor of 3.5, 1.9, and 1.4 for the sagittal, coronal, and torsion modes, respectively. Less motion occurred at the tibiotalar interface in all to the three different loading conditions (p = 0.031) with plate supplementation. CONCLUSIONS: Compared to screws alone, anterior plate supplementation increases construct rigidity and decreases micromotion at the ankle fusion interface.

Interobserver and intraobserver reliability of two classification systems for intra-articular calcaneal fractures.

BACKGROUND: For a fracture classification to be useful it must provide prognostic significance, interobserver reliability, and intraobserver reproducibility. Most studies have found reliability and reproducibility to be poor for fracture classification schemes. The purpose of this study was to evaluate the interobserver and intraobserver reliability of the Sanders and Crosby-Fitzgibbons classification systems, two commonly used methods for classifying intra-articular calcaneal fractures. METHODS: Twenty-five CT scans of intra-articular calcaneal fractures occurring at one trauma center were reviewed. The CT images were presented to eight observers (two orthopaedic surgery chief residents, two foot and ankle fellows, two fellowship-trained orthopaedic trauma surgeons, and two fellowship-trained foot and ankle surgeons) on two separate occasions 8 weeks apart. On each viewing, observers were asked to classify the fractures according to both the Sanders and Crosby-Fitzgibbons systems. Interobserver reliability and intraobserver reproducibility were assessed with computer-generated kappa statistics (SAS software; SAS Institute Inc., Cary, North Carolina). RESULTS: Total unanimity (eight of eight observers assigned the same fracture classification) was achieved only 24% (six of 25) of the time with the Sanders system and 36% (nine of 25) of the time with the Crosby-Fitzgibbons scheme. Interobserver reliability for the Sanders classification method reached a moderate (kappa = 0.48, 0.50) level of agreement, when the subclasses were included. The agreement level increased but remained in the moderate (kappa = 0.55, 0.55) range when the subclasses were excluded. Interobserver agreement reached a substantial (kappa = 0.63, 0.63) level with the Crosby-Fitzgibbons system. Intraobserver reproducibility was better for both schemes. The Sanders system with subclasses included reached moderate (kappa = 0.57) agreement, while ignoring the subclasses brought agreement into the substantial (kappa = 0.77) range. The overall intraobserver agreement was substantial (kappa = 0.74) for the Crosby-Fitzgibbons system. CONCLUSIONS: Although intraobserver kappa values reached substantial levels and the Crosby-Fitzgibbons system generally showed greater agreement, we were unable to demonstrate excellent interobserver or intraobserver reliability with either classification scheme. While a system with perfect agreement would be impossible, our results indicate that these classifications lack the reproducibility to be considered ideal.

Intermediate to long-term results of a treatment protocol for calcaneal fracture malunions.

BACKGROUND: Nonoperative management of displaced intra-articular calcaneal fractures may result in malunion affecting the function of both the ankle and the subtalar joint. The purpose of this study was to report the intermediate to long-term results of a treatment protocol for calcaneal fracture malunions. METHODS: Seventy feet (sixty-four patients) with a malunion after nonoperative management of a displaced intra-articular calcaneal fracture were evaluated. On the basis of the classification system of Stephens and Sanders, type-I malunions were treated with a lateral wall exostectomy and peroneal tenolysis; type-II malunions, with a lateral wall exostectomy, peroneal tenolysis, and subtalar bone-block arthrodesis; and type-III malunions, with a lateral wall exostectomy, peroneal tenolysis, subtalar bone-block arthrodesis, and a calcaneal osteotomy. The patients were evaluated clinically and radiographically at a minimum of twenty-four months following surgery. RESULTS: Forty-five feet in forty patients were available for follow-up evaluation at a minimum of two years, with an average duration of follow-up of 5.3 years. Thirty-seven (93%) of the forty feet that had an arthrodesis achieved union. Statistical analysis revealed no significant difference among the types of malunion with respect to the Maryland foot score, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score, or the Short Form-36 (SF-36) health survey subscales, which was likely due to sample size discrepancies. Forty-two (93%) of the forty-five feet were aligned in neutral or slight valgus hindfoot alignment, and all forty-five were plantigrade. Twenty-nine (64%) of the forty-five feet had mild residual pain, and nineteen of them had pain in the lateral aspect of the ankle. Radiographically, talocalcaneal height was significantly greater for the type-III malunion group relative to the type-I and type-II malunion groups (p = 0.021). CONCLUSIONS: This treatment protocol proved to be effective in relieving pain, reestablishing a plantigrade foot, and improving patient function. Because of the difficulty we encountered in restoring the calcaneal height and the talocalcaneal relationship in this group of patients with a symptomatic calcaneal fracture malunion, we believe that patients with a displaced intra-articular calcaneal fracture may benefit from acute operative treatment.

Experience with the vacuum assisted closure negative pressure technique in the treatment of non-healing diabetic and dysvascular wounds.

The purpose of this study is to report our experience with the Vacuum Assisted Closure (VAC) negative pressure technique in patients with non-healing wounds of the foot, ankle, and lower limb. We retrospectively reviewed 17 patients with non-healing wounds of the lower extremity who underwent treatment using the Vacuum Assisted Closure (VAC) device. Thirteen of 17 (76%) had diabetes mellitus, nine of whom were insulin-dependent, and 10 of whom had associated peripheral neuropathy. Eight of 17 (47%) had severe peripheral vascular disease. All had failed previous management with serial wound debridements and dressing changes; 15 of 17 (88%) had previously completed at least one course of oral antibiotics. Thirteen of 17 (76%) had previously undergone operative irrigation and debridement of the wounds; six of 17 (35%) had previously undergone revascularization procedures of the involved extremity. Five of 17 (29%) had wounds necessitating an amputation procedure prior to the present treatment; seven of 17 (41%) had failed treatment with local growth factors prior to the present treatment. Average length of treatment with the VAC device was 8.2 weeks. Fourteen of 17 (82%) wounds successfully healed; four underwent split-thickness skin grafting for wound closure; four were briefly treated with local growth factors; six were treated with only dressing changes following VAC treatment. Three of 17 (18%) wounds failed VAC treatment; all three patients had diabetes and had wounds located in the midfoot or forefoot; two of three had severe peripheral vascular disease. Our results indicate that the Vacuum Assisted Closure negative pressure technique is emerging as an acceptable option for wound care of the lower extremity. Not all patients are candidates for such treatment; those patients with severe peripheral vascular disease or smaller forefoot wounds may be best treated by other modalities. Larger wounds seem to be better suited for skin grafting or two-stage primary closure.

Preoperative considerations in ankle replacement surgery.

Total ankle arthroplasty continues to evolve as a viable treatment option for end-stage ankle arthritis. Proper patient selection is a critical aspect of promoting a successful result. Acceptable results have been reported in older, low-demand, nonobese patients who have osteoarthritis or rheumatoid arthritis. A significant percentage of patients with end-stage ankle arthritis, however, are younger patients with posttraumatic arthritis. Considerable controversy surrounds the use of ankle replacement in younger, more physically active patients and in those with significant deformity in the ankle or hindfoot. These patients should be approached cautiously because the risks and complications are still significant. More studies must be completed and further developments must be made to maximize the longevity and functional results of total ankle arthroplasty in future designs and applications.