Achilles tendon disorders: An overview of diagnosis and conservative treatment.

ABSTRACT: Achilles tendon-related pain affects up to 6% of the US population during their lifetime and is commonly encountered by primary care providers. An accurate diagnosis and early conservative management can improve patient quality of life and reduce unnecessary surgical consultations, saving healthcare dollars. Achilles tendon pathologies can be categorized into acute (pain lasting less than 6 weeks), chronic (pain lasting more than 6 weeks), and acute on chronic (worsening of pain with preexisting chronic Achilles tendon pathology). This article describes the diagnosis, conservative management, indications for imaging, and indications for surgical referral for acute and chronic Achilles tendon rupture, Achilles tendinitis, gastrocnemius strain, plantaris rupture, insertional Achilles tendinopathy, Haglund deformity, and noninsertional Achilles tendinopathy.

PROMIS Scores for Plantar Fasciitis Before and After Gastrocnemius Recession.

BACKGROUND: There has been an established relationship between increased loading on the Achilles tendon and tension on the plantar fascia. This supports the idea that either tight gastrocnemius and soleus muscles or contractures of the Achilles tendon are risk factors for plantar fasciitis. Gastrocnemius recession has gained popularity as a viable surgical intervention for cases of chronic plantar fasciitis due to isolated gastrocnemius contracture. To our knowledge, this is the first study to investigate Patient-Reported Outcome Measurement Information Systems (PROMIS) scores in patients with plantar fasciitis before and after gastrocnemius recession. METHODS: The Electronic Medical Record was queried for medical record numbers associated with Current Procedural Terminology code 27687 (gastrocnemius recession). Our study included all patients with a preoperative diagnosis of chronic plantar fasciitis with treatment via isolated gastrocnemius recession with 1-year minimum follow-up. Forty-one patients were included in our study. Patient variables were collected via chart review. Preoperative and postoperative PROMIS scores were collected in the clinic. RESULTS: We followed up 41 patients with a median age of 48 years (interquartile range [IQR] 38-55) and median body mass index of 29.02 (IQR 29.02-38.74) for 1 year post surgery. Preoperative and postoperative PROMIS scores improved for physical function from 39.3 to 44.5 (P = .0005) and for pain interference from 62.8 to 56.5 (P = .0001). PROMIS depression scores were not significantly different (P = .6727). Visual analog scale (VAS) scores significantly decreased from 7.05 to 1.71 (P < .0001). CONCLUSION: In this case series, we found the gastrocnemius recession to be an effective option for patients with refractory pain in plantar fasciitis. Our PROMIS and VAS data confirm this procedure's utility and highlight its ability to significantly decrease pain and improve physical function in patients with chronic plantar fasciitis, although final median scores did not reach normative standards for the population, suggesting some residual pain and/or dysfunction was, on average, present. Based on the results of this study, the authors conclude that gastrocnemius recession is a reasonable treatment option for chronic plantar fasciitis patients who fail nonoperative management. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

First Metatarsophalangeal Arthrodesis for Hallux Rigidus and Hallux Valgus: A Comparison of Patient Reported and Clinical Outcomes.

Few prior studies have compared the patient reported outcomes of first metatarsophalangeal arthrodesis between hallux rigidus and hallux valgus patients. Furthermore, we sought to examine the impact of postoperative radiographic hallux alignment on outcomes scores within each group. A retrospective review of 98 patients who a received primary metatarsophalangeal arthrodesis from January 2010 to March 2020. Clinical complications including nonunion were collected. Patient Reported Outcomes Measurement Information Systems (PROMIS) Physical Function, PROMIS Pain Interference, and the foot function index (FFI) revised short form scores were obtained via telephone. Patients were grouped based on review of preoperative radiographs of the foot and this grouping 37 hallux rigidus and 61 hallux valgus patients. Clinical and patient reported outcomes were compared between these pathologies. No differences in the rate of wound complications, radiographic union, and revision surgery were found between the 2 subgroups. At a median of 2.4 years (3.9 IQR) postoperatively, PROMIS and FFI scores did not vary by pathology group. For both groups, PROMIS scores were similar to the general population of the United States. The postoperative first MTP dorsiflexion angle in the hallux rigidus group was correlated with decreased FFI Pain, FFI Total, and PROMIS Pain Interference domain scores (|r| ≥ 0.40, p < .05 for all). When performing MTP arthrodesis in patients with hallux rigidus, increasing the first MTP dorsiflexion angle may correlate with improved intermediate term patient reported outcomes. However, further studies will need to be done to confirm this theoretical relationship.

A Novel Plating System for First Metatarsophalangeal Joint Arthrodesis: A Retrospective Comparison of Hybrid and Traditional Locking Plate Constructs.

BACKGROUND: Dorsal plate fixation is commonly used for first metatarsophalangeal joint (1st MTPJ) arthrodesis and plate design continues to evolve. A new staple compression plate (SCP) design attempts to utilize the continuous compression of a nitinol staple across the fusion site while simultaneously providing the stability of a dorsal locked plate. Herein, we compare the radiographic, clinical, and patient-reported outcomes of 1st MTPJ joint arthrodesis using 2 dorsal locking plate constructs including a novel SCP construct. METHODS: Forty-four patients who underwent 1st MTPJ arthrodesis between 2016 and 2020 were retrospectively evaluated. There were 2 group cohorts. Group 1 cohort included 23 patients who received a CrossRoads Extremity SCP, and Group 2 cohort included 21 patients who received a Stryker dorsal locking precontoured titanium plate (LPP). All patients were evaluated with radiographs, Patient-Reported Outcomes Measures Information System (PROMIS) outcome scores, and Foot Function Index (FFI). RESULTS: The complication and union rates did not vary between groups with a fusion rate of 95.7% in the SCP group and 90.5 % in the LPP group. Similarly, we found no significant differences in PROMIS or FFI scores between the SCP and LPP plates. CONCLUSION: Use of either dorsal locking plate construct for 1st MTPJ arthrodesis was associated with high union rates and comparable functional outcomes. As locked plate technology continues to evolve for 1st MTPJ arthrodesis, it is important that clinical outcomes are reported. LEVELS OF EVIDENCE: Level IV.

Prevalence and Risk Factors of Postoperative Falls Following Foot and Ankle Surgery.

BACKGROUND: No study has examined the incidence of risk factors for postoperative falls following foot and ankle surgery. We investigated the incidence and risk factors for postoperative falls in foot and ankle surgery using inpatient and outpatient population. METHODS: A single fellowship-trained foot and ankle surgeon instituted collection of a postoperative fall questionnaire at 2 and 6 weeks postoperatively. A retrospective review of 135 patients with complete prospectively collected fall questionnaire data was performed. Patient demographic information, injury characteristics, comorbidities, baseline medications, length of hospital stay, visual analog scale (VAS) pain scores were collected. After univariable analysis, a multivariable binary logistic regression was conducted to assess independent risk factors for postoperative falls. RESULTS: The median (interquartile range) age was 52 (21) and body mass index was 32.7 (11.1). A total of 108 patients (80%) underwent outpatient procedures. Thirty-nine of the 135 patients (28.9%) reported experiencing a fall in the first 6 weeks after surgery. In multivariable analysis, antidepressant use (adjusted odds ratio 3.41, 95% CI 1.19-9.81) and higher VAS pain scores at 2 weeks postoperatively (adjusted odds ratio 1.27, 95% CI 1.08-1.50) were found to be independent risk factors for postoperative falls. CONCLUSION: This study found a high incidence of postoperative falls in the first 6 weeks after foot and ankle surgery. Baseline antidepressant use and higher 2-week VAS pain scores were associated with postoperative falls. Foot and ankle surgeons should discuss the risk of falling with patients especially those with risk factors. LEVEL OF EVIDENCE: Level III, retrospective cohort study at a single institution.

Which surgical approach is optimal for joint preparation in talonavicular fusion - A cadaver study.

BACKGROUND: Fusion of the talonavicular joint has proven challenging in literature. The optimal surgical approach for talonavicular arthrodesis is still uncertain. This study compares the amount of physical joint preparation between dorsal and medial approaches to the talonavicular joint. METHODS: Twenty fresh frozen cadaver specimens were randomly assigned to receive either a dorsal or medial operative approach to the talonavicular joint. The joint surface was prepared, and the joint was disarticulated. Image analysis, using ImageJ, was performed by two blinded reviewers to assess the joint surface preparation and this was compared by surgical approach. RESULTS: The dorsal approach had a higher median percentage of talar and total talonavicular joint surface area prepared (75% vs. 59% (p = .007) and 82% vs. 70% (p = .005)). Irrespective of approach, the talus was significantly more difficult to prepare than the navicular (62% vs 88% (p = .001)). CONCLUSION: The dorsal approach provides superior talonavicular joint preparation. The lateral »th of the talar head was the most difficult surface to prepare, and surgeons performing double or triple arthrodesis may prepare the lateral talar head from the lateral approach. LEVEL OF EVIDENCE: Level V.

Impact of Patient Resilience on Outcomes of Open Brostrom-Gould Lateral Ligament Repair.

INTRODUCTION: Little is known about the factors affecting the intermediate outcomes of the Brostrom-Gould repair as measured by new patient-reported outcome instruments and the impact of patient resilience on postoperative outcomes. This is the first study to investigate the impact of resilience on the outcomes of lateral ligament repair. METHODS: Retrospectively, 173 patients undergoing Brostrom-Gould at single institution from January 2013 to June 2020 were identified. Patient characteristics, participation in athletic activities, surgical variables, and complications were recorded. Patient-Reported Outcome Measurement Information System (PROMIS) Pain Interference v1.1 (PI), Physical Function v1.2 (PF), and the Foot Ankle Ability Measure (FAAM) were collected. The Brief Resilience Scale was used to quantify resilience. A linear regression model was constructed to evaluate the independent effect of resilience on each PROMIS and FAAM outcome instrument. Variables were included in the regression model based on an a priori significance threshold of P <0.05 in bivariate analysis. RESULTS: Resilience's independent effect on outcome measures was as follows: PROMIS PF (unstandardized ß 8.2, 95% confidence interval [CI] 3.9 to 12.6), PROMIS PI (unstandardized ß -4.8, 95% CI -7.9 to -1.7), FAAM Activities of Daily Living (unstandardized ß 16.6, 95% CI 8.7 to 24.6), and FAAM Sports (unstandardized ß 28.4, 95% CI 15.9 to 40.9). Preoperative participation in athletic activities also had a positive independent effect on multiple outcome metrics including PROMIS PF (unstandardized ß 9.4, 95% CI 2.8 to 16.0), PROMIS PI (unstandardized ß -5.3, 95% CI -10.0 to -0.582), and FAAM Sport scores (unstandardized ß 34.4, 95% CI 15.4 to 53.4). CONCLUSIONS: Resilience and patient participation in athletic activities are independent predictors of improved postoperative functional outcomes as measured by PROMIS and FAAM instruments at intermediate term follow-up. Resilient patients and athletes reported markedly higher PF and less pain burden postoperatively. Preoperative quantification of resilience could enable improved prognostication of patients undergoing lateral ligament repair of the ankle.

First Metatarsophalangeal Joint Arthrodesis: A Narrative Review of Fixation Constructs and Their Evolution.

First metatarsophalangeal (MTP) joint arthrodesis is a surgical procedure in which the first metatarsal head is fused to the proximal phalanx of the great toe in order to permanently stiffen the first MTP joint. It was originally proposed as a treatment for severe cases of hallux valgus deformity, but the procedure's indications and utilization have expanded since its initial development. Despite a wide variety of indications, first MTP arthrodesis has been shown to have reliable, satisfactory outcomes. As a result, the development of a wide array of surgical approaches, joint preparation techniques, and fixation devices used in the procedure has occurred. In this narrative review, we highlight the evolution of fixation constructs used in first MTP arthrodesis in order to provide a frame of reference for the various types of fixation constructs available.

Diagnosis and conservative management of great toe pathologies: a review.

Acute great toe (Hallux) pain is a common complaint encountered by the primary care physician. Pathological conditions can vary from acute trauma to acute exacerbation of underlying chronic conditions. Delay in treatment or misdiagnosis can lead to debilitating loss of function and long-lasting pain. This review endeavors to discuss the pertinent history, physical exam findings, radiographic evidence, conservative treatment options, and surgical management for the musculoskeletal causes of acute and acute on chronic great toe pain in the adult population. The acute pathologies discussed in this review are hallux fractures and dislocations, turf toe, sand toe, and sesamoid disorders. The chronic pathologies discussed include hallux rigidus, hallux valgus, and chronic sesamoiditis.

Management of acute lesser toe pain.

Patients with foot pain commonly present to their primary care physicians for their initial management and treatment. These patients and their respective foot or lesser toe pain can present the physician with a complex problem with a long differential list. Depending on the timing of the pain and underlying pathology, these differentials can be divided into acute and acute exacerbation of chronic conditions. This review categorizes the history, physical exam, radiological findings, conservative treatment, and surgical management for each major cause of lesser toe pain, whether acute or chronic. The acute conditions surrounding lesser toe pain in the adult population discussed are toe fractures, toe dislocations, and metatarsal head and neck fractures. The chronic pathologies surrounding lesser toe pain in the adult population evaluated in this review include metatarsalgia, Morton's neuroma, Freiberg infraction, brachymetatarsia, bunionettes, and lesser toe disorders.

Suture Anchor-Enhanced Medial Capsulorrhaphy of the Great Toe.

The suture anchor-enhanced medial capsulorrhaphy of the great toe is utilized as an adjuvant procedure to proximal and distal osteotomies for the treatment of hallux valgus. In traditional open techniques, hallux valgus repair requires both osseous correction along with shortening of the capsule on the medial side of the metatarsophalangeal joint. Osseous correction typically corrects the intermetatarsal angle, whereas capsular correction maintains the hallux valgus angle1. Description: A standard medial approach to the 1st metatarsophalangeal joint is performed. A medial midline horizontal capsulotomy is performed starting just proximal to the medial eminence and extending distally to the base of the proximal phalanx. Once the concomitant osseous and soft-tissue procedures are completed, a vertical capsulotomy is made in the inferior capsular flap at the level of the metatarsophalangeal joint in a manner perpendicular to the first ray in order to form an L shape. A 3 to 4-mm wedge of capsule is formed near the base of the vertical limb, running obliquely to the horizontal limb, and is excised. Optionally, the free limbs of the inferior capsule are imbricated. A unicortical hole is then drilled in the first metatarsal head, and a 2.7-mm outer diameter by 7-mm deep suture anchor with 2-0 FiberWire (Arthrex) is placed. The free ends of the suture are then utilized to close the horizontal capsulotomy in a running-locking interrupted fashion. Fluoroscopic imaging is performed throughout the procedure to prevent overcorrection and varus malignment. Alternatives: Alternative treatments include L-shaped capsulorrhaphy without suture anchor augmentation, dorsolinear capsulorrhaphy, Y-shaped capsulorrhaphy, and proximal hallux osteotomy or distal hallux osteotomy without capsulorrhaphy. Rationale: Anchor-enhanced capsulorrhaphy has been proven to assist in early maintenance of hallux valgus angle correction when combined with relevant distal osteotomy techniques. The anchor-enhanced capsulorrhaphy has an advantage over traditional capsulorrhaphy methods because it allows enhanced tightening of the capsule to the bone and, therefore, the potential for enhanced short-term maintenance. Additionally, the use of a running-locking interrupted suture technique reduces the number of suture knots required for capsular closure, potentially reducing the chance of complications such as suture granuloma formation. This technique is useful in all patients with hallux valgus deformity because it helps to provide durable deformity correction through additional modification of the soft tissues surrounding the 1st metatarsophalangeal joint. Expected Outcomes: Medial capsulorrhaphy has been shown to help with short-term reduction of the hallux valgus angle, both with and without the use of suture anchors1-3. Gould et al. demonstrated the superiority of adding suture anchors to the L-shaped medial capsulorrhaphy in order to aid in prevention of early postoperative relapse of the valgus deformity in patients undergoing chevron or modified McBride osteotomy1. We have utilized this suture anchor-enhanced capsulorrhaphy technique as an adjuvant procedure in most patients receiving osteotomies or Lapidus procedures for hallux valgus correction with consistent, reproducible results. In our experience, the suture anchor-enhanced medial capsulorrhaphy is an effective and time-efficient adjunctive soft-tissue corrective procedure in hallux valgus patients. Important Tips: Always excise a small capsular wedge to start with.Throughout the capsular tightening process, utilize clinical judgment and fluoroscopy to avoid pulling the hallux into varus malalignment.If varus is noted during plication of the plantar capsule, simply undo the tightening stitch.Because the majority of capsular tightening occurs at the first distal knot during the running horizontal capsular closure, if varus is noted, untie the knot and proceed with less correction.The extra cost of the suture anchor is a drawback but should be weighed against the enhanced durability of capsular correction compared with a traditional capsulorrhaphy.Always check the position of the suture anchor under fluoroscopy before proceeding with capsular closure in order to ensure proper deployment and adequate osseous purchase.Suture anchor failure can cause misleading radiographic presentation or joint impingement. Acronyms and Abbreviations: VAS = Visual analog scaleAOFAS = American Orthopaedic Foot & Ankle SocietyHV = Hallux valgusHVA = Hallux valgus angleMTP = Metatarsophalangeal jointDVT = Deep venous thrombosis.