Ankle Stabilization With Arthroscopic Versus Open With Suture Tape Augmentation Techniques.

Ankle instability is a common problem that often leads to surgery to stabilize the ankle if conservative methods are unsuccessful in returning the patient to full activity. Surgical ankle stabilization, including arthroscopic and open methods, has been performed with overall excellent results reported. Although initial ligament strength after repair is weaker than the native ligament, new methods of augmentation with suture tape have yielded initial strength comparable to native ligament. The present study compares arthroscopic ankle stabilization and open stabilization with suture tape augmentation. A retrospective comparative trial was undertaken with a follow-up satisfaction survey. A total of 55 patients were ultimately included, consisting of 43 arthroscopic patients and 12 open with suture tape augmentation patients. Ancillary procedures are reported. The mean follow-up duration was 24.2 months in the arthroscopic group and 21 months in the open group. There was a statistically significantly faster return to activity/sports in the arthroscopic group (127.2 days vs 170 days; p = .008). Although not statistically significant, there was a trend toward favoring the open group in terms of revision surgery and patient satisfaction. Our data indicate that both methods of stabilization are reasonable for ankle instability repair.

Comparison and Use of Allograft Bone Morphogenetic Protein Versus Other Materials in Ankle and Hindfoot Fusions.

Bone grafting is a common procedure in foot and ankle surgery. Because autogenous graft use results in comorbidity to the patient, the search has been ongoing for the ideal substitute. A novel processing technique for allograft using bone marrow, which retains many of the growth factors, has shown promise in the spinal data and early reports of foot and ankle surgery. We performed a retrospective, comparative study of patients undergoing hindfoot and ankle arthrodesis, with a total of 68 patients included. Of the 68 patients, 29 (42.65%) received a bone morphogenetic protein allograft and 39 (57.35%) did not. The patient demographics and social and medical history were similar between the 2 groups and both groups had a similar time to union (p = .581). Of the 29 patients in the bone morphogenetic protein allograft group, 3 (10.3%) experienced nonunion and 4 (13.8%) developed a complication. Of the 39 patients undergoing other treatment, 7 (17.9%) experienced nonunion and 14 (35.9%) developed a complication. The difference for nonunion was not statistically significant (p = .5). However, the difference in the overall complication rate was statistically significant (p = .04). We found that this novel bone graft substitute is safe and can be used for foot and ankle arthrodesis.

Perioperative Complications and Initial Alignment of Lateral Approach Total Ankle Arthroplasty.

Total ankle replacement continues to become a more common treatment of end-stage ankle arthritis. A lateral approach total ankle implant system is an innovative approach for this treatment. We performed a retrospective review of 16 patients treated with lateral approach total ankle replacement. The implant was successful and retained in all cases during a follow-up period of 769 ± 221.3 days (25.3 ± 7.3 months). Initial satisfactory alignment was achieved in all cases. For patients in whom a frontal plane incongruent deformity was present preoperatively, a statistically significant correction was obtained (p = .0122). Three cases of delayed or nonunion of the fibula (18.8%) occurred, and one case of infection that led to removal of the fibular plate developed, for a total of 4 complications (25.0%) related to the fibular osteotomy. Our findings indicate that lateral approach total ankle replacement is effective with unique advantages and disadvantages for treating end-stage ankle arthritis.

Comparison of Chevron and Distal Oblique Osteotomy for Bunion Correction.

The chevron osteotomy is a standard procedure by which bunions are corrected. One of us routinely performs a distal oblique osteotomy, which, to the best of our knowledge, has not been described for the correction of bunion deformities. The purpose of the present study was to compare the short- and medium-term results of the distal oblique and chevron osteotomies for bunion correction. We performed a retrospective clinical and radiographic comparison of patients who had undergone a distal oblique or chevron osteotomy for the correction of bunion deformity. In addition, a prospective patient satisfaction survey was undertaken. A total of 55 patients were included in the present study and were treated from January 2012 to November 2014. Of the 55 patients, 27 (49.2%) were in the chevron group and 28 (50.8%) in the distal oblique group. Radiographically, no statistically significant difference was found between the 2 groups with respect to postoperative first intermetatarsal angle (p < .0001) and hallux valgus angle (p < .0001), but a greater change was found in the intermetatarsal angle in the distal oblique group (p = .467). Prospective patient satisfaction scores were available for 33 patients (60%), 16 (29%) in the chevron group and 17 (31%) in the distal oblique group. When converting the satisfaction score to a numerical score, the chevron group scored 3.3 ± 1.1 and the distal oblique group scored 3.2 ± 0.8 (p = .812). We found that the distal oblique osteotomy used in the present study is simple and reliable and showed radiographic correction and patient satisfaction equivalent to those in the chevron osteotomy.

Corrective Osteotomies Used in Cavus Reconstruction.

The authors dedicate this article to describing the clinical work-up and etiology for a cavus foot deformity as well as the surgical decision making for correction. Understanding and proper utilization of osteotomies is paramount in the improvement of cavus foot deformities. Also, the authors share their own experiences with preferred techniques for optimal outcomes.

Hindfoot Deformity Corrected With Double Versus Triple Arthrodesis: Radiographic Comparison.

Hindfoot fusion is capable of correcting hindfoot deformities. Typically, this has been done through triple arthrodesis. Recently, there has been some discussion of a double arthrodesis, sparing the calcaneocuboid joint. We compared the radiographic corrective ability of these 2 fusion techniques. A retrospective radiographic review was performed of 20 consecutive triple arthrodeses (triple) and 20 consecutive talonavicular and subtalar arthrodesis with calcaneocuboid preservation (double). Additional midfoot arthrodesis or osteotomy was performed as needed in each group. The preoperative measurements were compared to those from standing weightbearing films after fusion postoperatively. The angular measurements included the anteroposterior and lateral talar­first metatarsal line (Meary's and Simmons) and the anteroposterior and lateral talocalcaneal angle. Both groups demonstrated a statistically significant reduction in deformity and a return to more normal radiographic findings after arthrodesis (p < .05). The 2 groups did not differ statistically in preoperative deformity or correction obtained (p > .05). Traditionally, triple arthrodesis has been advocated for significant hindfoot deformity that is irreducible. Recent studies have questioned the need for inclusion of the calcaneocuboid joint in the arthrodesis, in particular, in a pronated, valgus-type foot. In addition, others have advocated a strictly medial approach to hindfoot fusion, necessarily avoiding the calcaneocuboid joint. Our findings agree with the assertion that hindfoot deformity can be adequately and reliably corrected through hindfoot arthrodesis whether or not the calcaneocuboid joint is included.

The fifth metatarsal base: anatomic evaluation regarding fracture mechanism and treatment algorithms.

Fractures occurring within the 1.5-cm proximal portion of the fifth metatarsal are commonly considered avulsion fractures. The exact mechanisms of such fractures are controversial. The present study focused on determining the likely mechanism of fracture according to the exact anatomy to allow for more successful treatment. The research sample included 10 frozen cadaveric specimens. The lateral band of the plantar fascia, peroneus brevis, and articular surface were identified and separated from their attachments, thereby splitting the fifth metatarsal base into zones A, B, and C. In zone A, the attachment of the plantar fascia was 6.6 ± 2.2 mm from the inferior aspect, 9.5 ± 2.9 mm from the proximal aspect, and 11.5 ± 0.9 mm from the lateral aspect. In zone B, the attachment of the peroneus brevis was 12.0 ± 2.2 mm from the inferior aspect, 10.2 ± 2.2 mm from the proximal aspect, and 11.5 ± 0.9 mm from the lateral aspect. Zone C was measured from the border of zone B and encompassed the articulation of the fifth metatarsal to the cuboid. We propose that fractures occurring in the most proximal end of the fifth metatarsal, zone A, are caused by a lateral band of plantar fascia and might be able to be treated conservatively by immobilization with weightbearing. We also propose that fractures occurring in zones B and C result from traumatic tension on peroneus brevis and might need to be treated with strict immobilization and non-weightbearing or open reduction internal fixation.

Retrograde Intramedullary Nail With Femoral Head Allograft for Large Deficit Tibiotalocalcaneal Arthrodesis.

BACKGROUND: Large bone defects present a difficult task for surgeons when performing single-stage, complex combined hindfoot and ankle reconstruction. There exist little data in a case series format to evaluate the use of frozen femoral head allograft during tibiotalocalcaneal arthrodesis in various populations in the literature. METHODS: The authors evaluated 25 patients from 2003 to 2011 who required a femoral head allograft and an intramedullary nail. The average time of final follow-up visit was 83 ± 63.6 weeks (range, 10-265). RESULTS: Twelve patients healed the fusion (48%). Twenty-one patients resulted in a braceable limb (84%). Four patients resulted in major amputation (16%). CONCLUSION: This series may allow surgeons to more accurately predict the success and clinical outcome of these challenging cases. LEVEL OF EVIDENCE: Level IV, case series.

Evans osteotomy and risk to subtalar joint articular facets and sustentaculum tali: a cadaver study.

The Evans lateral column lengthening procedure allows correction of abduction, improved talar head coverage, decreased forefoot and rearfoot valgus, and improvement of medial column arch height. However, identifying the structures at risk when performing this osteotomy has proved difficult in vivo. Using 10 cadaveric lower limbs, we performed the Evans calcaneal osteotomy and determined whether violation of the calcaneal facets and the sustentaculum tali occurred. Based on our findings, we recommend directing the osteotomy from posterolateral to anteromedial.

Predictive risk assessment for major amputation after tibiotalocalcaneal arthrodesis.

BACKGROUND: Tibiotalocalcaneal (TTC) arthrodesis using a nail has been shown to be an effective salvage technique; however, there is a risk of major amputation. A better understanding of the relative risk of amputation after TTC fusion and the factors that influence this could help the preoperative consultation and guide discussion on the economics of limb salvage. METHODS: One hundred seventy-nine limbs were treated with TTC fusion with an intramedullary nail. A comprehensive chart and radiographic review was pulled from our intramedullary nail database. Patients were divided into those who went on to eventual amputation and those with successful salvage of their limb. Variables from the database were used to build a statistical model with a biostatistician. Final results were presented, and a formula to determine probability of amputation was created. RESULTS: There were 21 limbs that were eventually treated with major amputation. This represents an overall salvage rate of 88.2% (158/179 patients). Age was a factor in amputation risk, and the highest risk factor for amputation was diabetes with an odds ratio of 7.01 and 95% confidence, P = .0019. The odds of amputation were 6.2 times and 3 times greater for patients undergoing revisions and those with preoperative ulcers, respectively. The probability of amputation could be found preoperatively by using the derived equation: e(x) /(1 + e(x) ) where x is a factor of age, diabetes, revision, and ulceration. CONCLUSION: TTC arthrodesis with a retrograde intramedullary nail has a high rate of limb salvage across a wide range of indications and medical comorbidities. In this patient cohort, diabetes was the most notable risk for amputation, followed by revision surgery, preoperative ulceration, and age. A model has been built to help predict the risk of amputation. LEVEL OF EVIDENCE: Level II, prognostic.

Agility to INBONE: anterior and posterior approaches to the difficult revision total ankle replacement.

Total ankle replacement is now acknowledged as a viable alternative to ankle arthrodesis for end-stage ankle arthritis. The authors present a series of 14 patients who were converted from the Agility total ankle replacement to an INBONE total ankle replacement. This report is unique in that anterior and posterior approaches are discussed and detailed. Although the authors present successful conversion of the Agility total ankle replacement to an INBONE total ankle replacement, the difficulty of this procedure is demonstrated by the high complication rate and 2 early failures.

The effect of recombinant bone morphogenetic protein-2 in revision tibiotalocalcaneal arthrodesis: utilization of the Retrograde Arthrodesis Intramedullary Nail database.

The use of bone morphogenetic protein-2 (BMP-2) has been recommended for high-risk fusions and nonunion. Patients undergoing revisional tibiotalocalcaneal (TTC) arthrodesis via a retrograde arthrodesis nail to evaluate the influence of BMP-2 on rate of fusion in this high-risk population are presented. A retrospective chart and radiographic review were performed on 23 patients with failed prior fusion attempts at the ankle treated with retrograde intramedullary nailing. Sixteen patients were treated without BMP-2 (None group) and 7 were treated with BMP-2 (BMP group). The primary and secondary end-points were successful fusion, and time to fusion, respectively, with a variety of variables evaluated for influence. Other than the use of BMP-2, there were no statistical differences in the patient population. Overall, 11 of 16 ankles (68.8%) in the None group and 5 of 7 ankles (71.4%) in the BMP group resulted in a stable, functional limb. Rate of complication was similar between the 2 groups (p > .05). Time to radiographic ankle union was 115.2 and 184.0 days in the None and BMP groups (p > .05). The effect of BMP-2 on revisional TTC fusions with retrograde nails is reported here. The overall result as a stable, functional limb was 69.6%, which suggests that revision surgery in this high-risk population is a reasonable consideration. Even though this study was unable to demonstrate statistically significant differences, biologic augmentation with BMP-2 did not increase the complication rate and showed a slightly enhanced salvage rate for revision TTC fusions with an intramedullary nail.

A retrospective comparative analysis of Charcot ankle stabilization using an intramedullary rod with or without application of circular external fixator--utilization of the Retrograde Arthrodesis Intramedullary Nail database.

Brodsky type 3a Charcot destruction of the ankle is devastating to patients. The authors have surgically stabilized this deformity with the use of an intramedullary arthrodesis nail, and explore the usefulness of adjunctive application of a circular external fixator. Fifty-two patients were treated with retrograde intramedullary nail with and without circular external fixation. A comprehensive chart and radiographic review were pulled from the Retrograde Arthrodesis Intramedullary Nail database. Of these, 45 patients were treated with a nail alone (Nail group), and 7 were treated with a nail and circular external fixation augmentation (ExFix group). The primary end point was major amputation or braceable limb. The average age was 59.4 and 51.6 years in the Nail and ExFix groups, respectively (p = .0068). Chronic steroid use was statistically significantly different and was found in 3 (6.7%) and 4 (57.1%) patients in the Nail and ExFix groups, respectively (p = .0039). The rate of major amputation was 10/45 (22.2%) and 2/7 (28.6%) in the Nail and ExFix groups, respectively (p = .656), with an overall salvage rate of 40/52 limbs (75.6%). The addition of circular external fixation does not affect the overall salvage or complication rate. The authors feel that the added stability offered by external fixation may benefit patients who are at high risk for complications or require extended arthrodesis, but this was unable to be demonstrated statistically in this study. Patients with this difficult pathology can be successfully salvaged, but there is a high risk of complications.

Revision total ankle replacement: an early look at agility to INBONE.

INTRODUCTION. The role of total ankle replacement (TAR) is expanding in the United States. As the number of ankles implanted increases, undoubtedly the number of failures will increase. Several reports in the literature have dealt with salvage of the failed TAR through various methods. MeTHODS. A retrospective chart and radiographic review was performed on all patients who had conversion from a failed Agility TAR to an INBONE TAR at 2 centers and had been performed at least 12 months prior to the study. Exclusion criteria included any patient converted from a different type of TAR, primary TAR, patients followed less than 12 months, and surgical approach other than the standard anterior incision. RESULTS. Five patients met inclusion criteria. The average age was 65.6 ± 13.6 years (range = 45-79 years). Complicating comorbidities were found with 4 patients. The average follow-up was 17.2 ± 6.6 months (range = 7-25 months). The cause of failure of the original Agility TAR was coronal plane deformity in 3 patients, and 1 patient each failed from extensive heterotopic ossification or infection. All patients presented with pain. In 4 cases, there was component subsidence at the talus, tibia, or both. All patients had adjunctive procedures at the time of the revision, including malleolar screw placement in 4 patients and hindfoot arthrodesis in 2 patients. All patients had either 4 or 5 tibial stem components placed. During the follow-up period, 3 patients required additional surgery, including 2 patients classified as failures (1 transtibial amputation and 1 tibiotalocalcaneal arthrodesis). DISCUSSION. This salvage option is technically demanding. The authors caution against TAR revision by conversion in the place of previous infection and in ankle imbalance not amenable to reconstruction. In all cases the initial deformity was corrected. The early results, however, demonstrate high risk of early failure and positional changes.

Cannulated screw fixation of Jones fifth metatarsal fractures: a comparison of titanium and stainless steel screw fixation.

The classic Jones fracture involves the fifth metatarsal at the level of the proximal diaphyseal-metaphyseal junction. The mainstay of surgical treatment for the Jones fracture is intramedullary screw fixation. There is no consensus of the type or material of screw that should be used. The purpose of this retrospective cohort study was to test the hypothesis that there is no clinical difference in the incidence of healing, or complications, when comparing stainless steel to titanium cannulated screws used in Jones fracture open-reduction internal fixation (ORIF). Data were collected on a total of 53 patients (fractures) that were fixed with either cannulated titanium screws (Ti group) or cannulated stainless steel screws (SS group). The postoperative protocol was standardized. The mean time to radiographic union was 11.7 ± 5.1 weeks in the Ti group and 13.4 ± 5.7 weeks in the SS group (P = .333). The overall union rate for the Ti group was 36/37 (97%) and 14/16 (88%) in the SS group (P = .213). Complications were rare in both groups, and the prevalence was not statistically significantly different (P > .05). There was 1 patient with an asymptomatic radiographic nonunion in the Ti group, and this patient elected not to undergo revision. There were 2 nonunions in the SS group. One was revised and went on to heal and the other is awaiting revision. Our study has demonstrated the decision to use stainless steel or titanium can be left to patient constraints, such as allergies, or physician preference without compromising the clinical result.

Fixation of first tarsometatarsal arthrodesis: a retrospective comparative cohort of two techniques.

BACKGROUND: Presently, indications for the Lapidus procedure include patients with many pathologies of the first metatarsocuneiform joint. Currently the standard in many areas is that of two or three crossed screws through the first tarsometatarsal region. This type of fixation requires an extended period of nonweightbearing and may be difficult for patient compliance. MATERIALS AND METHODS: The present study is a retrospective comparison of crossed screw fixation to locking plate fixation without a lag screw on union rates, time to weightbearing, and complications. RESULTS: One hundred forty-three first TMT fusions met the inclusion criteria. There were 96 fused by crossed screw construct (CS) and 47 by the locked plate with or without compression screw (LP). There was a significant difference in time to full weightbearing and union rate. Time to full weightbearing was 8.8 (range, 3 to 16) weeks and 7.8 (range, 1.5 to 34) weeks in the CS and LP groups, respectively (p < 0.001). Union rate was 89.4% (88 of 96 joints) and 98.5% (46 of 47 joints) in the CS and LP groups, respectively (p < 0.001). CONCLUSIONS: We found that when using a dorsal-medial locked plate with or without lag screw lead to a superior rate of union compared to standard crossed screw constructs even while allowing earlier return to full weightbearing.

Retrograde intramedullary nail arthrodesis for avascular necrosis of the talus.

BACKGROUND: Avascular necrosis (AVN) of the talus from any etiology is a devastating pathology. There are few salvage options available and controversy exists as to the surgical management for patients with talar AVN. The authors present their results of tibiotalocalcaneal arthrodesis with a retrograde nail. MATERIALS AND METHODS: A comprehensive chart and radiographic review was pulled from our database for patients with AVN of the talus, who were treated by tibiotalocalcaneal fusion with retrograde intramedullary nail. Primary outcome was union, with time to clinical union as a secondary endpoint. RESULTS: Fourteen patients were included. The average age at surgery was 47.4 ± 12.8 years, there were nine female patients, and the average Body Mass Index was 33.5 ± 6.0. Surgical risk factors included two patients who smoked, one was diabetic, and one had a preoperative ulceration. The average time to partial weightbearing was 70.6 ± 25.4 days, and the average time to full weightbearing was 100.6 ± 35.5 days. Four patients had postoperative complications, while no patients required major revision surgery. Twelve patients went on to solid fusion, while two went on to a stable, braceable pseudoarthrosis. Eight patients were able to return to shoes, and eight were able to walk unaided at final followup. CONCLUSION: Salvage of talar AVN is possible by tibiotalocalcaneal arthrodesis with an intramedullary nail. Physicians may offer this as a salvage option to patients with a high likelihood of successful fusion.

Autogenous bone graft harvest using reamer irrigator aspirator (RIA) technique for tibiotalocalcaneal arthrodesis.

Tibiotalocalcaneal arthrodesis is a technically demanding procedure that can be associated with a high number of complications, including nonunion. Bone grafting is commonly used in arthrodesis procedures to decrease the risk of nonunion. In this article, we describe a technique that uses a reamer-irrigator-aspirator (RIA) method for procurement of autogenous bone graft for use in tibiotalocalcaneal arthrodesis fixated with a retrograde intramedullary nail. Using the RIA technique, autogenous bone graft can be readily obtained without the need for additional incisions and dissection, thereby minimizing the need for additional sources of bone graft.

Understanding levels of evidence for scientific communication.

Foot & Ankle Specialist (FAS) is adding a "level of evidence" rating to all new submissions. This is important as evidence-based medicine in practice is increasingly important. The rationale for adding this rating to FAS publications is multifaceted. It will encourage researchers to design better projects and become adept at critically evaluating research. It will put research publications into appropriate context, and it will guide the profession in general to a higher level of scientific analysis. Four types of studies will be used at FAS: therapeutic, prognostic, diagnostic, and economic/decision making. Within each of these types of studies, levels of evidence between I and V can be assigned. A description of each type and explanation of how to assign evidence level is given. This may assist authors and readers as they work to design projects and critically evaluate literature.