Proximal Medial Gastrocnemius Recession for Recalcitrant Plantar Fasciitis.

BACKGROUND: Recalcitrant plantar fasciitis (RPF) is characterized by its unresponsiveness to conservative treatments, and its surgical management remains controversial. Although there is some evidence to suggest that gastrocnemius recession can be an effective treatment for RPF, no large series of patients with mid- to long-term follow-up has been published. The objective of this study was to compare physical performance, as measured by the Foot and Ankle Ability Measure activities of daily living score (FAAM-ADL), and pain levels before and 1 year after undergoing proximal medial gastrocnemius recession (PMGR) as a treatment for RPF. Additionally, we aimed to assess this cohort of patients in the mid- to long-term follow-up. METHODS: This retrospective cohort study included 167 patients who underwent PMGR to address RPF between 2009 and 2021. Patients were examined with the FAAM ADL, visual analog scale (VAS) and satisfaction scores at baseline, 1 year, and at the end of follow-up. Other variables recorded were weight, duration of symptoms until surgery, time between surgery to substantial clinical improvement, calf power and Silfverskiold test, and postoperative complications. RESULTS: We observed that before surgery patients had an FAAM-ADL score of 22.5 (SD 11.1) and a VAS score of 8.6 (SD 9.3). One year after surgery, patients had an FAAM-ADL score of 89 (SD 17) and VAS of 1.33 (SD 2) (P < .01). We also observed that the FAAM-ADL score in the long-term follow-up (>12.5 years) group had a median of 86.4 (SD 22.6), the VAS score was 1.90 (SD 2.84), and the patient satisfaction score had a median of 1 (interquartile range 0-1). Regarding complications, we observed 1 lateral gastrocnemius recession and 1 sural nerve neuritis. CONCLUSIONS: Our study provides substantial evidence supporting the use of PMGR as an effective treatment for RPF. The long-term follow-up and large sample size of our series contribute to the existing literature on this topic. LEVEL OF EVIDENCE: Level IV, case series.

A Radiologic Triangle Sign for Percutaneous Adductor Tendon Release (PATR): Cadaveric Study and Case Series.

Background: Combining osteotomies and soft tissue procedures is believed to reduce sesamoids in their anatomical position and maintain long-term correction when treating hallux valgus deformity. This study determines if a radiologic association exists between a radiolucent sign and a full percutaneous adductor tendon release (PATR), including a cadaveric study and a consecutive case series. Another aim was to determine the intra- and interobserver reliability of these observations. Methods: A prospective observational study was made between 2018 and 2019. First, a PATR was done on cadaveric specimens and, after the procedures, dissected to correlate what was seen fluoroscopically. The clinical group included 39 feet that presented mild-to-moderate HV deformity and were treated with percutaneous osteotomies associated with PATR. Results: Observers 1 and 2 saw a radioscopic radiolucent sign in 100% of cadavers and the patient population. They also observed a triangle-shaped image with an incidence of 75%, which we have named the "triangle sign." Conclusion: The triangle sign may be helpful in the intraoperative confirmation of PATR and latero-plantar capsule release using this percutaneous technique. Level of Evidence: Level II, development of diagnostic criteria.

Republication of "How Accurate Is Clinical Evaluation in Hindfoot Coronal Alignment?"

Background: Hindfoot coronal alignment is an important factor in the assessment of patients with many different foot and ankle complaints. A number of clinical and radiographic techniques have been described to measure hindfoot coronal alignment, but none of them are widely accepted. The purpose of the present study was to assess the correlation between clinical and radiographic hindfoot alignment measures and to evaluate the reproducibility of each. Methods: We evaluated 85 patients with foot and/or ankle symptoms. Hindfoot clinical alignment was measured from photographs. Each patient was placed at a distance of 1 m from the observer, with both feet placed parallel. Four photographs were taken, at a height of 40 cm: a posterior view of both lower limbs including knees, a posterior view focalized on the studied hindfoot, an anterior view of the foot, and the last view of the medial aspect of the foot. Radiographic alignment was quantified on long axial view radiographs. Patients were lying over the film cassette with a focus distance of 1 m and the beam pointed to the ankle joint. The inclination angle of the beam was 45 degrees to the floor. Measurements were independently made by 2 observers, who were asked to classify pictures into 3 categories: varus, neutral, and valgus. Radiographic measurements were made using the angle measurement tool on the radiograph viewer. The intraclass correlation coefficients (ICCs) and the 95% confidence interval (CI) of the ICC were used to quantify the inter- and intraobserver reliability for clinical assessment. Radiographic parameters were correlated by calculating the Pearson correlation coefficient (r). Results: The intraobserver ICC for clinical analysis was good for both observers, while the interobserver ICC was moderate for both measurements. Regarding radiographic assessment, there was significant intra- and interobserver reliability. The correlation between both methods was weak for both observers. Conclusions: We found only weak intra- and interobserver correlations between the clinical and radiographic assessment of hindfoot coronal alignment. It is therefore necessary to complement the clinical evaluation of hindfoot alignment with an objective measurement method such as a long axial view radiograph. Further studies comparing different measurement methods need to be performed to establish the most objective evaluation. Level of Evidence: Level III, diagnostic study.

Abordaje del seno del tarso para el tratamiento de las fracturas de calcáneo: una técnica de creciente difusión / Sinus tarsi approach for the treatment of calcaneus fractures: an increasingly used technique

Objetivo: Describir los resultados radiográficos y funcionales, y las complicaciones de la osteosíntesis de fracturas de calcáneo mediante el abordaje del seno del tarso. Materiales y Métodos: Se evaluaron 54 fracturas articulares de calcáneo desplazadas en 50 pacientes con radiografías de pie, de frente y de perfil, y tomografía computarizada preoperatorias. Se tomaron radiografías de pie, de frente y de perfil sin carga en el posoperatorio inmediato y con carga a las semanas 6 y 12, y al final del seguimiento. Se midió el ángulo de Böhler y se cuantificó el grado de artrosis subastragalina y calcaneocuboidea. Se determinó el puntaje de la AOFAS y se registraron las complicaciones de la herida, las lesiones neurológicas y la necesidad de cirugías adicionales, como retiro del material de osteosíntesis y artrodesis subastragalina. Resultados: El seguimiento fue de 30.8 meses. La serie estaba formada por 8 mujeres y 42 hombres, con una edad de 39.40 ± 14 años (rango 18-65). Cuarenta fracturas eran Sanders tipo II, 13 tipo III y 1 tipo IV. El puntaje de la AOFAS fue: excelente (12 casos), bueno (25 casos), regular (12 casos) y malo (5 casos). El ángulo de Böhler preoperatorio era de 10,8 ± 10,4° y 30,77 ± 8,24° al final del seguimiento (p <0,00001). El 3,7% tuvo complicaciones menores de la herida y el 5,6%, complicaciones mayores. Conclusión: El abordaje del seno del tarso permite una reducción aceptable con resultados buenos y excelentes en la mayoría de los pacientes y escasas complicaciones de partes blandas. Nivel de Evidencia: IV

Objective: To describe functional and radiographic outcomes, and complications of osteosynthesis in calcaneus fractures with the sinus tarsi approach. Materials and Methods: 54 displaced articular calcaneus fractures in 50 patients were assessed through preoperative foot radiographs (anteroposterior and lateral) and computerized tomography. AP and lateral radiographs were obtained in the immediate postoperative period (without weightbearing), after 6 and 12 weeks (with weightbearing), and at the end of follow-up, measuring the Böhler angle and quantifying the degree of subtalar and calcaneocuboid osteoarthritis. The AOFAS score was determined, registering wound complications, neurological injuries and necessary additional surgeries -such as osteosynthesis and subtalar arthrodesis hardware removal. Results: Follow-up time was 30.8 months. The series consisted in 8 women and 42 men. The patients' average age was 39.40±14 years (18-65). There were 40 Sanders type II, 13 type III, and 1 type IV fractures. The AOFAS score was excellent (12 patients), good (25), regular (12), and poor (5). The Böhler angle was 10.8°±10.4° before surgery, and 30.77°±8.24° at the end of follow-up (p<0.00001). 3.7% of the patients presented minor wound complications, while 5.6% presented major wound complications. Conclusion: The sinus tarsi approach allows for acceptable reduction with good and excellent outcomes in most patients, coupled with few soft-tissue complications. Level of Evidence: IV

A Refined Minimally Invasive Distal First Metatarsal Osteotomy for Moderate Hallux Valgus Treatment: The BC Procedure.

During the last 2 decades, there was an increasing interest in mini-invasive procedures for hallux valgus correction. In this scenario the Bösch technique appears to be a reproducible distal metatarsal osteotomy (DMO) to achieve a proper correction. Our DMO variant, called BC, was planned to combine the stability and predictability of the chevron osteotomy, with the power of correction, low surgical time and mini-invasive approach of the Bösch-SERI technique. The purpose of this investigation is to describe the surgical technique and report the results of this modified procedure at a minimum 2-year follow-up. Sixty-three patients who underwent the BC technique for mild and moderate hallux valgus were prospectively evaluated. Mean follow-up was 36.5 (range 23.4-59.8) months, the mean American Orthopedic Foot and Ankle Society score improved from a median of 47.4 points preoperatively to a median of 88 points postoperatively (p < .05). First MTPJ ROM did not change from preoperative period (mean 32.5°) to the postoperative period (mean 31.8°) (p > .65). All osteotomies went on to bony healing in the 6-week follow-up visit. Fifty-two (82%) of patients were either very satisfied or satisfied with the procedure (p < .05). With our numbers, BC osteotomy is shown to be a technique that can treat both mild and moderate deformities, achieving correction that is maintained over the follow-up evaluated, with a 24 relatively simple procedure and short operative time.

Correction Power of Percutaneous Adductor Tendon Release (PATR) for the Treatment of Hallux Valgus: A Cadaveric Study.

Osteotomies are commonly used in order to correct hallux valgus deformity. However, soft tissue structures also play an essential role in the etiology, progression, and treatment of hallux valgus (HV). The purpose of the present study was to analyze the correcting power (varus), reduction strength (sesamoid) and rotation of metatarsal and proximal phalanx after percutaneous adductor tendon release (PATR). To date, no study addresses this issue. Eleven cadaveric fresh-frozen below-the-knee cadaveric lower limbs with associated hallux valgus deformity were used. These specimens were subjected to a constant abduction force after PATR. HV and intermetatarsal angles showed statistically significant differences when comparing the preoperative and postoperative periods. PATR showed to be a reliable technique as the adductor tendon was completely released in 9 cases, and 75% released in the remaining 2 feet. The study supports that PATR provides powerful and quantifiable correction of HV deformity and can be accurately performed percutaneously.

Current Concepts in Treatment of Acute Deltoid Instability.

Although far less common than lateral ankle injuries, medial ankle sprains have been reported to result in significantly greater time lost and long-term disability when not diagnosed and treated accurately. Adequate diagnosis is paramount and the most important aspect is to determine whether the lesion is stable or unstable. Evidence confronting surgical versus conservative treatment in acute deltoid ligament lesions is largely anchored in the setting of ankle fractures. Ultimately treatment decisions rely on the clinical and imaging appraisal of each individual patient. This article discusses the isolated acute deltoid ligament impairment.

Factores asociados con dolor severo en pacientes con fascitis plantar: Un análisis de relaciones / Factors associated with severe pain in patients with plantar fasciitis: An association analysis

Objetivo: Describir los factores asociados con niveles de dolor mas severo en una cohorte de pacientes con fascitis plantar. El objetivo secundario fue analizar cuales de estos factores estaban asociados con niveles mas altos de mejoria clinica luego del tratamiento conservador. Materiales y Métodos: Se evaluo a una cohorte prospectiva de pacientes con diagnostico de fascitis plantar. Cada participante completo una escala ordinal visual de dolor (del 1 al 10) para dolor del primer paso y dolor al final del dia y encuestas FFI-R (Foot Function Index-Revised). Tambien se realizo una evaluacion demografica. La dorsiflexion de la articulacion del tobillo, el rango de movilidad de la primera articulacion metatarsofalangica, la rigidez del gastrocnemio y el angulo popliteo tambien se evaluaron de manera estandar. Resultados: Se incluyo a 214 pacientes. El 64% eran hombres (118 pacientes), la media de la edad era de 49.67 anos (DE 13.16) y el indice de masa corporal promedio, de 28,53 (DE 5,18). En el analisis multivariado, se observo que el riesgo de un puntaje ≥8 en la escala de dolor aumento cuando el paciente refirio estar de pie por mas de 6 h (OR 1,17; p = 0,03; IC95% 1,02-1,35). El riesgo de un puntaje >8 fue mayor cuando el grado de dorsiflexion del tobillo fue <0° (OR 1,20; p = 0,03; IC95% 1,02-1,41). Conclusión: Nuestros hallazgos apoyan indirectamente la hipotesis de que la dorsiflexion limitada del tobillo juega un papel como factor de riesgo asociado a un puntaje ≥8 en la escala de dolor, en los casos de fascitis plantar. Nivel de Evidencia: IV

Objective: The main purpose of our study was to describe the factors associated with more severe pain levels in a cohort of patients with plantar fasciitis (PF). The secondary purpose of this study was to determine which of these factors were associated with higher levels of clinical improvement after conservative therapy. Materials and Methods: We conducted a prospective study in a cohort of patients with PF. Each participant completed an ordinal pain scale (1-10) for first-step pain and end-of-day pain, and Foot Function Index-Revised (FFI-R) surveys at enrollment. Also, patient demographics were evaluated. The ankle joint dorsiflexion, the range of motion (ROM) for the first metatarsophalangeal joint (MTPJ), the gastrocnemius tightness, and the popliteal angle were evaluated through standard tests. Results: Our study included 214 participants, of which 64% (118 patients) were males, the average age was 49.67 years (SD 13.16) and the average BMI was 28.53 (SD 5.18). The multivariate analysis showed that the risk of having a Visual Analog Scale (VAS) score ≥8 increased when the patient reported standing for more than 6 hours (OR=1.17; P=0.03; CI95%: 1.02-1.359). The risk of a >8-VAS score was higher when the level of ankle dorsiflexion was <0 (OR=1.20; P=0.03; CI95%: 1.02-1.41). Conclusion: Our findings indirectly support the hypothesis that limited ankle dorsiflexion ROM plays a role as a risk factor associated with VAS scores ≥8 in PF patients. Level of Evidence: IV

Youngswick osteotomy for treatment of moderate hallux rigidus: Thirteen years without arthrodesis.

PURPOSE: The purpose of this study was to evaluate the need for first metatarsophalangeal joint (MTPJ) arthrodesis as a measure of the Youngswick osteotomy survival, or any other secondary procedures in the long term follow up in patients with stage II and III hallux rigidus. METHODS: We retrospectively evaluated 61 patients with stage II and III hallux rigidus who had undergone Youngswick osteotomy and analyzed their outcomes in the long term using first metatarsophalangeal arthrodesis as an end point. The candidates for inclusion underwent clinical and radiographic evaluation, including the Foot and Ankle Outcome Score (FAOS). RESULTS: Mean follow-up time was 54.8 months. All patients had improved their FAOS, with all achieving postoperative scores >75 points at the final follow up (P<0.05). Although 49 % (P<0.05) of the patients depicted worsening of the radiological aspect of the MTPJ, over the long time, no patient needed a first MTPJ arthrodesis. CONCLUSION: Our results show satisfying long-term outcomes with regard to function, pain relief, and patient satisfaction of the Youngswick osteotomy in grade II as well as grade III hallux rigidus that sustained over the follow up period; even in patients followed up for over 13 years. LEVEL OF EVIDENCE: III.

Mini thigthrope® fixation of unstable bony avulsion of the extensor hallucis longus tendon.

Reports of isolated avulsion fracture of the distal phalanx of the hallux that comprise the functionality of the extensor hallucis longus tendon (EHL) are scarce and treatment for such injury has only been described in isolated single case reports. Two patients with an unstable avulsion fracture of the distal phalanx treated with reinsertion of the EHL with a Mini ThigthRope® system are presented in this paper. Two patients whom suffered an extreme plantarflexion mechanism sought attention in our clinic. Plain x-rays depicted a displaced and angulated bony avulsion fracture of the base of the distal phalanx of the hallux. The interphalangeal joint was in a slightly plantarflexed position and the patient was not able to perform active extension upon request. Surgical fixation performed with Mini ThigthRope® system without transarticular immobilization of the interphalangeal joint. In the two patients the Mini ThigthRope® system provided adequate reduction of the displaced articular fragment, restored the extensor function and allowed early postoperative mobilization of the IP joint. Removal of the implants was not necessary and patients were able to resume their previous activity levels. Level of Evidence: IV.

Metatarsalgia: Assessment Algorithm and Decision Making.

Historically, metatarsalgia was approached as a forefoot condition, most often associated with hallux valgus. Consequently, surgical treatments were limited to that anatomic zone, disregarding more proximal structures. In order to assess this entity properly, it is necessary to consider anatomic and biomechanical factors, as well as general and local conditions of the affected patients. A thorough understanding of the multiple potential causal factors is essential to ensure selection of the optimal treatment.

Gastrocnemius Recession in the Setting of Metatarsalgia: The Baumann Procedure.

A fundamental etiologic component of metatarsalgia is the repetitive loading of a locally concentrated force in the forefoot during gait. In the setting of an isolated gastrocnemius contracture, weight-bearing pressure is shifted toward the forefoot. If metatarsalgia is considered an entity more than a symptom, evaluation of gastrocnemius contracture must be a part of the physical examination, and gastrocnemius recession via the Baumann procedure alone, or in combination with other procedures, considered as an alternative treatment in an attempt to restore normal foot biomechanics.

What Are the Benefits and Risks Associated With the Use of Vancomycin Powder in the Wound During Total Ankle Arthroplasty (TAA) or Other Foot and Ankle Procedures?

RECOMMENDATION: Though one study supporting topically applied vancomycin has shown it to reduce the rate of deep infection in diabetic patients undergoing foot and ankle surgery, there is insufficient evidence to show benefits or to show any risks associated with the use of vancomycin powder during total ankle arthroplasty (TAA) or other foot and ankle procedures in a general population. LEVEL OF EVIDENCE: Consensus. DELEGATE VOTE: Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Should Routine Methicillin-Resistant Staphylococcus aureus (S. aureus), or MRSA, Screening Be in Place Prior to Total Ankle Arthroplasty (TAA)?

RECOMMENDATION: Unknown. The role of screening for methicillin-resistant Staphylococcus aureus (MRSA) and decolonization prior to total ankle arthroplasty (TAA) remains unclear. Further data are needed to support this practice in TAA, which can be costly and logistically difficult to implement. LEVEL OF EVIDENCE: Consensus. DELEGATE VOTE: Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

What Metrics Can Be Used to Determine the Optimal Timing of Reimplantation in Patients Who Have Undergone Resection Arthroplasty as Part of a Two-Stage Exchange for Infected Total Ankle Arthroplasty (TAA)?

RECOMMENDATION: There is no conclusive data regarding what metrics can be used in order to determine the optimal timing of reimplantation for an infected TAA. We recommend that reimplantation is performed when there are clinical signs of resolution of infection (well-healed wound, lack of erythema, etc), and the serologic markers have substantially declined (>40%) from baseline (measured at the time of diagnosis of infection). LEVEL OF EVIDENCE: Consensus. DELEGATE VOTE: Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Are there any risk factors for developing complications with the use of retrievable vena cava filters in orthopaedic surgery?

BACKGROUND: In high-risk patients, common prophylaxis may be insufficient to prevent thromboembolic events after orthopaedic procedures. In this scenario, a retrievable vena cava filter (VCF) could be considered as an alternative, although it's use remains controversial. Therefore, we asked: (1) what is the overall mechanical complication rate associated with the use of retrievable VCFs in orthopaedic surgery?, (2) what is the association with thromboembolic disease (TED) recurrence, post-thrombotic syndrome and/or major bleeding according to different surgical characteristics?, (3) What is the overall mortality rate attributed to VCF use? METHODS: We retrospectively analyzed a cohort of 68 patients who underwent orthopaedic surgery with a previous diagnosis of TED, in whom a retrievable VCF was placed. Permanent filters were excluded. We studied the filter's mechanical complications and considered as possible outcomes death and 3 hematologic complications: TED recurrence, post-thrombotic syndrome and major bleeding. To estimate association with risk factors, we subclassified surgeries into 5 groups: 1, arthroplasty/non-arthroplasty; 2, primary/revision; 3, elective/urgent; 4, oncologic/non-oncologic; 5, preoperative/postoperative filter. RESULTS: Mechanical complications were 16% and required a filter revision. Sixty-four percent of the revised VCFs developed a mechanical failure and could not be retrieved. Overall prevalence of TED recurrence, post-thrombotic syndrome and hemorrhage was 33%, 15% and 4.5%, respectively. Spinal surgeries were a risk factor for developing TED recurrences.  Only 4% of patients died of a TED recurrence. CONCLUSIONS: Orthopaedic procedures had a high risk of mechanical and hematologic complications after using a retrievable VCF. However, mortality was low due to these complications.