Percutaneous Arthroscopic Calcaneal Osteosynthesis: A Minimally Invasive Technique for Displaced Intra-Articular Calcaneal Fractures.

The management of calcaneal fracture remains challenging. Open surgery has been fraught with high infection rates and soft tissue complications. More minimally invasive procedures have reduced this risk, but the patient outcomes after treatment of displaced calcaneal fractures have remained relatively unsatisfactory. We present a method for the management of Sanders grade II and III calcaneal fractures: percutaneous arthroscopic calcaneal osteosynthesis. Thirty-three fractures in 30 patients who had presented to our tertiary foot and ankle trauma center in central London were treated with percutaneous arthroscopic calcaneal osteosynthesis for calcaneal fractures, and the data were prospectively collected. The mean patient age at injury was 39 years. The mean follow-up period was 24 months. Of our patients, 58% were smokers at injury. Of the 33 fractures, 46% were classified as grade II and 54% as grade III. The mean length of stay was 1.92 days. At the final follow-up visit, the mean Böhler angle had increased from 11.10° (range 2° to 24°) to 23.41° (range 15° to 35°). The modified American Orthopaedic Foot and Ankle Society scale score was 72.18 (range 18 to 100), the calcaneal fracture scoring system score was 79.34 (range 42 to 100), and the visual analog scale score was 29.50 (range 0 to 100). We had a single case of a superficial port site infection and 2 cases of prominent screws, which were removed. No cases of deep infection developed, and no conversion to subtalar fusion was required. This technique significantly reduced the incidence of postoperative wound complications. Direct visualization of the fracture site allowed accurate restoration of the articular surface and correction of heel varus. Furthermore, it was associated with a high self-reported functional outcome and a return to preinjury employment levels. Also, the results did not appear to be influenced by tobacco consumption.

Lisfranc injury in the athlete: evidence supporting management from sprain to fracture dislocation.

Although Lisfranc injuries are uncommon, prompt and accurate diagnosis of such injuries in athletes is essential in preventing career-ending injury. Undisplaced injuries have an excellent result with nonoperative treatment. The presence of any displacement warrants open reduction and anatomic fixation; although current evidence mostly supports screw fixation, plate fixation may avoid joint intrusion. It is imperative to warn athletes with significantly displaced injuries that there is a risk of a poor outcome, although some recent evidence suggests that return to elite competitive sports is still likely after surgical intervention. Severe injuries may have better outcomes with limited arthrodesis.

Lisfranc injuries: an update.

Lisfranc injuries are a spectrum of injuries to the tarsometatarsal joint complex of the midfoot. These range from subtle ligamentous sprains, often seen in athletes, to fracture dislocations seen in high-energy injuries. Accurate and early diagnosis is important to optimise treatment and minimise long-term disability, but unfortunately, this is a frequently missed injury. Undisplaced injuries have excellent outcomes with non-operative treatment. Displaced injuries have worse outcomes and require anatomical reduction and internal fixation for the best outcome. Although evidence to date supports the use of screw fixation, plate fixation may avoid further articular joint damage and may have benefits. Recent evidence supports the use of limited arthrodesis in more complex injuries.

First metatarsophalangeal arthrodesis using a dorsal plate and a compression screw.

BACKGROUND: Fusion of the first metatarsophalangeal joint is considered a `gold standard' procedure for arthritis and as a salvage procedure for previous failed surgeries. Recent biomechanical studies have shown that a combination of a plate and screw is the most stable construct. Only a few studies have evaluated this combination and they have small cohorts so we are presenting our larger series of patients. MATERIALS AND METHODS: Forty-six consecutive cases of first metatarsophalangeal joint fusion performed between April 2006 and April 2008 were performed using a dorsal plate and a compression screw. We analyzed the outcome in terms of fusion rate, patient satisfaction and complication rates. The average followup period was 23 (range, 14 to 37) months. The most common indications were hallux rigidus and severe hallux valgus. RESULTS: Ninety-eight percent of the cases fused uneventfully by four months. The average time to fusion was 3.1 months. There was one non-union, which remained asymptomatic after metal removal which was the only case requiring removal of metal. There was no hardware failure. The patient satisfaction was 100%. The average AOFAS score was 82.1 (maximum, 90). CONCLUSION: These results show that arthrodesis of the first MTP joint with spherical reamers and a low-profile contoured dorsal titanium plate and compression screw is highly successful, with excellent patient satisfaction and functional outcomes. We recommend the use of specially designed plates against improvised plates as bending leads to poor control over dorsiflexion and may increase the incidence of plate failure.

A comprehensive review of subtalar arthrodesis.

BACKGROUND: The aim of this study was to evaluate the results of a series of subtalar arthrodeses done by a single surgeon using a standard technique. METHODS: A retrospective review of 95 primary isolated subtalar arthrodeses in 92 patients was done. Original diagnoses included post-traumatic subtalar arthrosis, primary osteoarthrosis, talocalcaneal coalition, and inflammatory joint disease. In all arthrodeses, a single 7.0-mm partially-threaded cancellous screw was used for fixation, and autogenous bone graft was used. Structural iliac crest autograft was required to restore heel height in three feet with post-traumatic arthrosis. In these three, autograft was harvested from the iliac crest with the remainder receiving morcellized autograft either from the tibia, fibula, or calcaneus. RESULTS: No patients were lost to followup. Ninety-five percent (87) of patients went on to bony union radiographically. Using the Angus and Cowell rating system, 93% (88 feet) of patients had a good or fair outcome. There were seven poor results: four arthrodeses failed to unite, two patients had persistent hindfoot pain in spite of radiographic union, and one developed post-traumatic ankle arthrosis. CONCLUSIONS: The results of isolated subtalar arthrodesis using a single screw for fixation are comparable to other fixation methods. Bone graft from local sites obviates the need for iliac crest autograft in most patients.

The response of the flexor digitorum longus and posterior tibial muscles to tendon transfer and calcaneal osteotomy for stage II posterior tibial tendon dysfunction.

BACKGROUND: The purpose of this prospective study was to evaluate the response of the flexor digitorum longus (FDL) and posterior tibial (PT) muscles to FDL tendon transfer and medial displacement calcaneal osteotomy for stage II posterior tibial tendon dysfunction (PTTD). METHODS: Twelve patients were divided into two groups, depending on whether the PT tendon was excised (Excised Tendon Group) or left intact (Intact Tendon Group). The muscle volumes of the FDL and PT muscles in both legs were measured and compared, using cross-sectional area (CSA) analysis of preoperative and postoperative MRI. RESULTS: Preoperatively, there was an average 11% reduction in the PT muscle volume and a 17% increase in the FDL muscle volume from the normal contralateral side in both groups. One year after surgery (average 13.4 months) in both groups, the FDL muscle volume had increased by an average of 27% and the PT muscle volume had decreased by 23% compared to the contralateral normal side. The FDL volume increased by 44% in the Excised Tendon Group compared to 11% in the Intact Tendon Group. The PT muscle volumes were not assessed in the Excised Tendon Group because all PT muscle had been replaced by fatty infiltration. The PT volumes in the Intact Tendon Group decreased further from a 6% reduction preoperatively to a 23% reduction postoperatively compared to the normal contralateral side. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores increased from 50 preoperatively to 88 at 1 year after surgery. There was no difference in the scores between the Excised Tendon (47 to 87) and Intact Tendon (53 to 89) groups. CONCLUSION: We concluded that the FDL muscle hypertrophies in response to a failing PT muscle. This hypertrophy continues after FDL transfer and medial displacement calcaneal osteotomy. With excision of the PT tendon, the FDL undergoes greater hypertrophy than if the tendon is left attached. The PT muscle continues to atrophy and undergoes complete fatty replacement if the tendon is excised. Transfer of the FDL and medial displacement calcaneal osteotomy produce a satisfactory improvement in hindfoot function; the outcome was the same whether the PT tendon was sacrificed or left intact.