Tibiotalocalcaneal arthrodesis.

The purpose of this multicenter retrospective study of 55 patients (56 ankles) who underwent simultaneous tibiotalocalcaneal arthrodesis with severe disease involving the ankle and subtalar joints was to determine improvement of pain and function. The surgical indications included osteoarthritis, posttraumatic injury, failed previous surgery, talar avascular necrosis, osteoarthritis, and rheumatoid arthritis involving the ankle and subtalar joints. The average age at the time of the operation was 53 years. The average time of follow-up was 26 months after the operation. Fusion was achieved in 48 ankles, with an average time of fusion of 19 weeks. Forty-eight of the 55 patients were satisfied with the procedure. The average leg length discrepancy was 1.4 cm. The average amount of dorsiflexion was 2 degrees and plantar flexion was 5 degrees. Following surgery, 42 patients complained of pain, 40 patients required shoe modification or an orthotic device, and 34 patients had a limp. Fourteen patients described their activity as unlimited. Based on the AOFAS evaluation, the patients scored an average of 66 on the ankle-hind foot scale following surgery. The most common complications were nonunion (8 ankles) and wound infection (6 ankles). This study demonstrates that tibiotalocalcaneal arthrodesis is an effective salvage procedure for patients with disease both involving the ankle and subtalar joints.

Austin bunionectomy: postoperative MRI evaluation for avascular necrosis.

The authors used magnetic resonance imaging (MRI) to evaluate the formation rate of avascular necrosis following performance of 20 modified Austin bunionectomies. Five modified McBride bunionectomies without first metatarsal osteotomy were also performed as an MRI control. Results showed an avascular necrosis formation rate of 50%. The majority of the avascular necrosis areas were found dorsally within the cancellous bone substance of the first metatarsal head. These lesions, in all cases, did not cause any patient disability or result in any decline in the degree of patient satisfaction. The MRI positive avascular necrosis evaluations do suggest potential problem areas with the surgical technique that may be eliminated through further modification of the classic Austin bunionectomy procedure.

Ankle fusion.

Multiple techniques for ankle arthrodesis have been described. A transfibular lateral approach between the sural nerve and the lateral branch of the superficial peroneal nerve is utilized. This permits excellent visualization of the ankle joint so that correction of the deformity can readily be achieved under direct visualization. Eighteen ankle fusions carried out through a transfibular approach were reviewed. The fusion site was stabilized with two or more 6.5-mm AO screws. No bone graft was utilized. The follow-up period was from six to 48 months. Ages of the patients ranged from 21 to 68 years. The postoperative regimen was six weeks nonweight-bearing in a short-leg cast, followed by weight bearing in a short-leg cast until union occurred. All fusions but one healed with an average period of 14 weeks of immobilization. No patient experienced wound healing difficulty or disruption of a superficial nerve. The authors believe that this is a simple technique that permits excellent visualization through a safe internervous interval, good bone apposition, rigid interfragmentary fixation and does not require the use of bone graft.

Results of Akin type proximal phalangeal osteotomy for correction of hallux valgus deformity.

The results of 26 Akin proximal phalangeal osteotomies in 22 patients for hallux valgus deformities are reported. The average follow up was 53 months (range, 12 to 97 months). Subjectively, 16 feet had a satisfactory result (61.5%). Objectively, 14 feet met the criteria for a satisfactory result (53.8%). The authors found that the Akin osteotomy was unpredictable as an isolated procedure, and not indicated in a hallux valgus deformity with an incongruent joint.

Isolated chondral fractures of the knee.

Eighteen patients with isolated chondral fractures of the knee were reviewed to reevaluate the clinical signs and symptoms. No other conditions had been present to account for the symptoms. Most of the patients had significant injuries often involving a flexed knee. All patients had had symptoms and physical findings strongly suggestive of meniscal abnormality. Roentgenographic examinations were noncontributory. The lesions occurred in four distinct patterns. All were full thickness. Many of the lesions occurred on the posterior aspect of a femoral condyle, a location where they could be easily overlooked if the condyle were not examined with the knee in extreme flexion. Abutment of the tibial spine against the medial femoral condyle may be one cause of these injuries. The incidence of isolated chondral fractures was found to be higher than previously reported. A negative arthroscopic meniscal examination in a patient with symptoms and physical findings suggestive of meniscal abnormality should alert the physician to the possibility of an isolated chondral fracture.