High Utility of the 1st Metatarsal Phalangeal Joint Fusion.

Fusion of the first metatarsophalangeal joint has been used by foot and ankle surgeons as a reproducible and useful means of treating end-stage arthritis of the great toe. However, the overall utility and successful outcomes of this procedure have led to its incorporation into the treatment of more significant bunion deformities, reconstruction forefoot, and salvage procedures. The authors review surgical fixation methods, offer insightful technical pearls for challenging cases and share examples of complex reconstructive and salvage procedures.

Anterior Ankle Incision Wound Complications Between Total Ankle Replacement and Ankle Arthrodesis: A Matched Cohort Study.

The anterior incision is commonly used for total ankle replacement (TAR) and ankle arthrodesis. Historically, the anterior incision has demonstrated a high incidence of complications. The purpose of this study was to evaluate anterior incisional healing and soft tissue complications between TAR and ankle arthrodesis with anterior plate fixation.This was an IRB-approved retrospective review of wound healing and other complications among 304 patients who underwent primary TAR (191 patients) or ankle arthrodesis (113 patients) via the anterior approach over a 4-year period. The operative approach, intraoperative soft tissue handling, and postoperative protocol for the first 30 days were the same between groups. The mean follow-up was 11.8 months. To diminish the effect of selection bias, a subgroup analysis was performed comparing 91 TAR patients matched to an equal number of demographically similar ankle arthrodesis patients. Overall, 19.7% of patients experienced delayed wound healing greater than 30 days. Although the TAR and arthrodesis subgroups had dissimilar demographics, there was no difference in outcomes. Between matched pairs, no statistically significant differences were observed; however, trends were identified with matched cohort groups when compared to the overall patient series. These trends toward statistically significant differences in delayed wound healing and incidence of wound care in the matched cohort groups warrants further investigation in larger series or multicenter study. Further work is needed to identify the modifiable risk factors associated with the anterior ankle incision.

Beaming in Charcot Arthropathy-Intramedullary Fixation for Complicated Reconstructions: A Cadaveric Study.

In the modern treatment of Charcot neuroarthropathy, beam screw fixation is an alternative to plate and screw fixation. Exposure is minimized for implantation, and this technique supports the longitudinal columns of the foot as a rigid load-sharing construct. A published data review identified a paucity of data regarding metatarsal intramedullary canal morphology relevant to beam screw fixation. The purpose of the present study was to describe metatarsal diaphyseal morphology qualitatively and quantitatively in an effort to provide data that can be used by surgeons when selecting axially based intramedullary fixation. Twenty fresh-frozen cadaveric below-the-knee specimens were obtained. The metatarsals were exposed, cleaned of soft tissue, and axially transected at the point of the narrowest external diameter. Next, a digital caliper was used to measure the size and shape of the diaphysis of the first through fourth metatarsals. The diaphyseal canal shape was categorized as round, oval, triangular, or pear. The widest distance between the endosteal cortical surfaces was measured. Triangular endosteal canals were only found in the first metatarsal, and the remainder of the metatarsal canals were largely round or oval. These data help to approximate the size of fixation needed to achieve maximal screw-endosteal purchase.

Clinical Adaptation of the "Tibiofibular Line" for Intraoperative Evaluation of Open Syndesmosis Reduction Accuracy: A Cadaveric Study.

BACKGROUND: The "tibiofibular line" is a new axial computed tomography parameter for assessing syndesmosis reduction, which references the flat anterolateral surface of the fibula and anterolateral tibial tubercle. These same bony landmarks are easily visualized via a lateral approach to the fibula. This cadaveric study assessed the practical aspects of measuring the tibiofibular line intraoperatively. METHODS: Three observers simulated the tibiofibular line using operative rulers in 3 measurement series utilizing 10 cadaveric specimens: intact syndesmosis, syndesmosis reduction, and fixation after application of lateral plate and screws to the fibula, and post syndesmosis reduction and fixation without plate and screws. RESULTS: The majority (78%) of clinical tibiofibular line measurements were within the "normal" range (0-2 mm). However, there was a general trend toward malreduction (>2 mm) across measurement series. Intraobserver variability ranged from poor to excellent (intraclass correlation range, 0.12-0.85, Fleiss kappa range, 0.19-0.40) and interobserver reliability was only generally in the fair range (intraclass correlation range, 0.49-0.61; Fleiss kappa range, 0.19-0.40). CONCLUSION: Taken as a whole, these findings found that the technique was feasible but clearly indicated that further refinement of this protocol, including the use of computed tomography, would be needed to determine if better control of confounding variables would reveal better observer reliability. CLINICAL RELEVANCE: The CT-based TFL technique for syndesmosis reduction assessment could not reliably be translated into an intraoperative open technique because of the confounding effects of subjectivity and operator error.