The Ankle Joint: Management of Significant Bone Loss with Arthrodesis.

Segmental bone loss of the distal tibia and/or talus presents a challenge to successful reconstruction for the foot and ankle surgeon. When conservative care has been exhausted, multiple surgical treatment options are available including bone transport, bulk allografts, bulk autografts, titanium cages, and external fixation techniques. The primary goals of surgical correction include restoration of limb length as well as a plantigrade, stable lower extremity.

Addressing varus and valgus deformity of the ankle: Algorithmic approach to total ankle arthroplasty.

Total ankle replacements have become increasingly popular, providing a viable alternative to ankle arthrodesis in patients with end stage ankle arthritis. Continued advancements in implant design have substantially improved long term survival outcomes as well as patient pain relief, range of motion, and quality of life. Surgeons continue to advance the indications for implantation of total ankle replacements in patients with more severe varus and valgus coronal plane deformity. This report of twelve cases demonstrates our algorithmic approach to total ankle arthroplasty in patients with deformity of the foot and ankle. By proposing a clinical algorithm with case examples, we aim to aid clinicians in successfully approaching coronal plane deformities of the foot and ankle when using total ankle replacement to ultimately improve clinical outcomes.

Medial Malleolar Screw Length to Achieve Thread Purchase in the Dense Bone of the Tibial Epiphyseal Scar Location Based on CT Model.

Medial malleolar ankle fractures are one of the most common surgically treated fractures of the ankle joint. Current AO guidelines for medial malleolar fractures recommend 2 partially threaded cancellous screws across the fracture line. For these screws to cross the fracture line, the threads must purchase the distal tibial metaphysis, which is an area of decreased bone density especially in elderly osteoporotic bone. The epiphyseal scar of the tibia is the densest portion of distal metaphysis of the tibia, and it has been determined that bone density decreases significantly further proximal through the tibia. One hundred eighty-three individual weightbearing coronal CT scans were assessed to measure the location of the epiphyseal scar and propose an ideal screw length to purchase this area and remain within the distal most portion of the tibia. In following with this criteria it was determined that a 34 mm ⅓ thread pattern screw and a 38 mm ½ thread pattern screw would suffice for 92.6% and 75.3% of males, respectively. It was determined that a 30 mm ⅓ thread pattern screw and a 32 mm ½ thread pattern screw would suffice for 93.4% and 85.3% of females, respectively. This study proposes optimal screw lengths in a theoretical area of increased bone density that may decrease complications in patients with compromised bone quality.

A Novel Manipulation Technique for Lapidus Fusion in Correction of Hallux Valgus Deformity With Underlying Metatarsus Adductus: A Case Series.

Underlying metatarsus adductus (MA) is commonly seen in patients with hallux valgus (HV) deformity, with implications regarding procedure selection and hallux valgus recurrence. Lapidus, or first tarsometatarsal fusion, is commonly performed allowing reduction in intermetatarsal angle (IMA) but this procedure has not been established as an approach to provide partial correction of MA deformity. Retrospective assessment of preoperative and postoperative metatarsus adductus angle (MAA), IMA and hallux abductus angle (HAA) in patients treated with Lapidus fusion for HV. Significance was determined via paired t test with a p value of <.05. All cases involved manual transverse plane manipulation to reduce both IMA and MAA during screw insertion. Intermetatarsal angle and Engel's angle were measured on preoperative AP radiographs to determine the presence of underlying MA in patients undergoing Lapidus fusion for HV. Ten weeks and 1 year postoperative radiographs were measured to determine degree of correction of IMA, HAA, and MAA. Thirty-four patients met inclusion criteria, which is approximately 46% of our sample population. The average preoperative IMA was 19.4˚ (range 12-32) and the average postoperative IMA was 9.7˚ (range 6-14). The average preoperative Engel's angle was 27.4˚ (range 24-34) and the average postoperative Engel's angle was 22.6˚ (range 15-28) with mean improvement in MA of 6.6˚. Of the 34, 27 (79.4%) patients had a normal Engel's angle at 10 weeks postoperatively. All measures of change met level of significance (p < .05). Of the 34 patients, 21 had radiographs taken beyond the 1 year mark (average 53 weeks). These patients were found to have an average Engel's angle of 23.0˚, which is not statistically significantly different from their 10 week measurements. Of the 21 patients, 17 (81%) maintained normal Engel's angle past 1 year. Metatarsus adductus varies regarding degree of reducibility and complicates preoperative angular measurement and correction of HV. Based on these findings, we recommend Lapidus fusion using this specified manipulation technique to obtain comprehensive transverse plane correction.

Ideal Angle of Upper and Lower Syndesmotic Fixation Based on Weightbearing Computed Tomographic Imaging in Uninjured Ankles.

Syndesmotic fixation remains a controversial topic, however most authors recommend fixation of the disrupted syndesmotic complex in unstable ankle fractures. There is no clear reference for the angle of syndesmotic fixation, historically 30° has been cited but recently refuted, with new and current literature. It is common practice to place 2 points of transyndesmotic fixation one with fixation placed at around 2 cm above the ankle joint and the second point approximately 3.5 cm above the plafond. Our hypothesis is that the ideal angle of transyndesmotic fixation is less than 30° and that the ideal angle changes when you move proximal from the 2-cm level to 3.5-cm level. This is based on cross-sectional anatomy as seen on weightbearing computerized tomography imaging. It is imperative to achieve adequate reduction of the syndesmosis to prevent instability and a malaligned ankle joint, as this can result in refractory pain and early onset of degenerative changes. We reviewed 50 weightbearing computerized tomography scans of the foot and ankle to identify what we call the adjusted syndesmotic fixation angle. Our review found adjusted syndesmotic fixation angle to be 19.7° with ranges of (8°-31°) at 2 cm and 24.8° with ranges of (14°-38°) at 3.5 cm above the tibial plafond. These values were statistically significant when compared to historically cited 30°. Our research concludes that the historically cited 30° angle is frequently not the ideal angle for syndesmotic fixation and actually is less.