Comparison of rates of union and hardware removal between large and small cannulated screws for calcaneal osteotomy.

BACKGROUND: The calcaneal osteotomy is a common procedure to correct hindfoot malalignment. Reported union rates are high, utilizing fixation methods including staples, plates, and most commonly cannulated screws. We began our practice using 6.5 mm and 7.3 mm cannulated screws, but complaints of postoperative posterior heel pain led to hardware removal in many patients. A switch to smaller 4.5 mm cannulated screws resulted in fewer symptoms, thus we hypothesized that using a smaller screw would decrease screw removal while maintaining an equally high union rate. METHODS: The records of patients who underwent a calcaneal osteotomy by 2 surgeons between January 1996 and April 2012 were retrospectively reviewed. The rates of hardware removal and union were compared between osteotomies held with two 7.3 mm, 6.5 mm, and 4.5 mm cannulated screws. RESULTS: There were 272 feet that met the inclusion criteria. The hardware removal rate for 130 osteotomies held with two 7.3 mm screws was 29.2% and the removal rate for 115 osteotomies held with 4.5 mm screws was 13.0%, which was significantly different (P < .05). The removal rate for 27 osteotomies with 6.5 mm screws was 33.3%. The union rate for all groups was 100%. CONCLUSION: Fixation of calcaneal osteotomies with two 4.5 mm screws is advantageous over larger screws with respect to future hardware removal. There was no loss of position from the smaller screws and we feel that the 4.5mm cannulated screw provides sufficient compression and achieves a high rate of union equal to that of the larger screws. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Talonavicular arthroscopy for osteochondral lesions: technique and case series.

BACKGROUND: Traditional treatment of talonavicular osteochondral lesions (OCLs) requires an open procedure. Arthroscopic microfracture of talonavicular OCLs may provide a viable, minimally invasive approach. The purpose of this study was to describe an arthroscopic approach for treatment of talonavicular OCLs, describe the proximity of arthroscopic portals to important structures in cadaver specimens, and report magnetic resonance imaging (MRI) findings and clinical outcomes of this technique. METHODS: Five cadaver specimens were dissected so proximity of portals to adjacent tendons and neurovascular structures could be assessed. Subsequently, 3 athletic patients with OCLs of the talonavicular joint were treated with arthroscopic debridement and microfracture. Patient records and imaging studies were retrospectively reviewed. RESULTS: In the cadaver specimens, the mean distance between the neurovascular bundle and the medial border of the extensor hallucis longus (EHL) was 9.0 (range, 8 to 10) mm. The saphenous nerve was located a mean of 6.8 (range, 6 to 7) mm from the medial border of the tibialis anterior tendon. Therefore, portals were placed just medial to the EHL and tibialis anterior tendon to avoid the neurovascular bundle and saphenous nerve, respectively. In all patients, access, identification of the OCL, debridement, and microfracture were successfully performed. All patients demonstrated improvements in Foot and Ankle Outcome Scores and Short Form-12 scores and began gradual return to activity within 12 weeks following the operation. No significant complications occurred. MRI indicated signal consistent with reparative fibrocartilage in all patients. CONCLUSION: Talonavicular arthroscopy allowed visualization, curettage, synovectomy, loose body removal, and microfracture of OCLs that would have otherwise required an open approach. At early follow-up, all patients had returned to their previous activity levels. Arthroscopy of the talonavicular joint was a viable approach for microfracture of OCLs. LEVEL OF EVIDENCE: Level IV, case series.

Anterior ankle arthrodesis.

Ankle arthrodesis is a common procedure that resolves many conditions of the foot and ankle; however, complications following this procedure are often reported and vary depending on the fixation technique. Various techniques have been described in the attempt to achieve ankle arthrodesis and there is much debate as to the efficiency of each one. This study aims to evaluate the efficiency of anterior plating in ankle arthrodesis using customised and Synthes TomoFix plates. We present the outcomes of 28 ankle arthrodeses between 2005 and 2012, specifically examining rate of union, patient-reported outcomes scores, and complications. All 28 patients achieved radiographic union at an average of 36 wk; the majority of patients (92.86%) at or before 16 wk, the exceptions being two patients with Charcot joints who were noted to have bony union at a three year review. Patient-reported outcomes scores significantly increased (P < 0.05). Complications included two delayed unions as previously mentioned, infection, and extended postoperative pain. With multiple points for fixation and coaxial screw entry points, the contoured customised plate offers added compression and provides a rigid fixation for arthrodesis stabilization.

Morbidity and complications following percutaneous calcaneal autograft bone harvest.

BACKGROUND: Autogenous bone grafting is commonly used as an adjuvant in foot and ankle procedures. The iliac crest and tibia are common sources of autogenous bone graft but require a separate operative site and have been reported to have significant morbidity including pain, fractures, and prolonged hospitalization. Bone grafting from the posterolateral calcaneus offers advantages such as a single operative field, ability to be done under an ankle block, and a theoretical low complication rate. We report our morbidity and complications of percutaneous calcaneal autograft bone harvest in patients undergoing foot operations. METHODS: Between 2006 and 2010, 6 foot and ankle surgeons performed a calcaneal bone graft on 393 patients undergoing foot procedures. Outcomes were measured through the use of a 4-question survey evaluating pain, subjective sensitivity at the incision site, numbness at the incision site, and limitation of shoe wear at a minimum of 1 year following the operation. Patient records were also examined for any additional complications that may have been reported. RESULTS: Of the 393 patients eligible for this study, 210 patients responded at an average of 2.8 years (range, 1.2-5.8 years) after the operation (minimum 1 year). Of those, 181 patients (86.2%) reported no problems. Minor complications included 6 patients (2.9%) who experienced only incisional nerve sensitivity, 4 patients (1.9%) with only incisional pain, 4 patients (1.9%) who reported some degree of incisional numbness only, 2 patients (1.0%) who reported only shoe wear limitations, and 10 patients (4.8%) who had a combination of symptoms. Three patients (1.4%) had more significant complications, which consisted of a pathological fracture through the graft site, a calcaneal stress fracture, and 1 patient with permanent numbness along the distribution of the sural nerve. CONCLUSION: Calcaneal bone graft was an easily accessible source of local autogenous bone graft for foot and ankle procedures. Despite the simplicity of the procedure, minor complications are not infrequent, with 13.8% of patients reporting some residual symptoms along the lateral border of the calcaneus when bone graft was obtained through an oblique incision. LEVEL OF EVIDENCE: Level IV, case series.

Treatment of Advanced Stages of Hallux Rigidus with Cheilectomy and Proximal Phalangeal Osteotomy: Surgical Technique.

INTRODUCTION: We believe that a combination of cheilectomy and proximal phalangeal osteotomy can be used successfully (with an 85% satisfaction rate1) in patients with advanced hallux rigidus, including those in whom it is classified as Hattrup and Johnson2 Grade III or as Coughlin and Shurnas3 Grade III or IV (extensive degeneration of the joint involving >50% of the articular surface). STEP 1 SURGICAL APPROACH: Begin with a dorsal approach to the first metatarsophalangeal joint and phalanx. STEP 2 CHEILECTOMY: Remove osteophytes and the dorsal third of the first metatarsal head. STEP 3 PROXIMAL PHALANGEAL OSTEOTOMY: Perform a 3-mm dorsal-based closing-wedge osteotomy of the proximal phalanx. STEP 4 CLOSURE AND POSTOPERATIVE PROTOCOL: Close the metatarsophalangeal joint capsule and skin. RESULTS: We reviewed the results in eighty-one patients with advanced hallux rigidus who were treated with a combination of cheilectomy and proximal phalangeal osteotomy. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.