The Efficiency of Highly Porous ß-Tricalcium Phosphate With Bone Marrow Aspirate Concentrate in Midfoot Joint Arthrodesis.

BACKGROUND: Nonunion is one of the most common and devastating complications following midfoot joint arthrodesis. Many different types of bone grafts and bone substitutes have been used to promote osseous fusion. However, there is no consensus on the gold standard bone grafting material and whether biologic materials should be used alone or in combination. The purpose of this study is to investigate the efficiency of highly porous ß-tricalcium phosphate (ß-TCP) with bone marrow aspirate concentrate (BMAC) in midfoot joint arthrodesis. METHODS: This retrospective comparative study included patients who underwent midfoot joint arthrodesis using compression screws. Patients were classified into 2 groups: arthrodesis with highly porous ß-TCP and BMAC (group A) and arthrodesis without them (group B). The osseous union rate was compared between the 2 groups. A total of 44 patients (46 feet) including 89 joints were included in this study. RESULTS: There was a significant difference in the union rate between the 2 groups: 91.5% (43/47 joints) in arthrodesis with highly porous ß-TCP and BMAC (group A) and 76.2% (32/42 joints) in arthrodesis without highly porous ß-TCP and BMAC (group B; P = .048). CONCLUSION: This study investigated the efficiency of highly porous ß-TCP and BMAC to promote bony healing in midfoot joint arthrodesis. A significantly higher union rate was shown when arthrodesis was performed with highly porous ß-TCP and BMAC, compared with arthrodesis performed without them. We suggest that highly porous ß-TCP and BMAC can be a viable and effective adjunct to the fixation in midfoot joint arthrodesis. LEVEL OF EVIDENCE: Level III: Retrospective comparative analysis.

Republication of "Uses of Braces and Orthotics for Conservative Management of Foot and Ankle Disorders".

Nonsurgical management is almost always considered the first-line treatment for the vast majority of foot and ankle pathologies. Foot orthoses, shoe modifications, and therapeutic footwear are considered essential tools for successful conservative management of different foot and ankle disorders. Orthopedic foot and ankle surgeons should have a meticulous understanding of the lower extremity biomechanics as well as the pathoanatomy and the sequelae of diseases affecting the foot and/or ankle. This is essential to the understanding of the desired effects of the different inserts, orthotics, shoe modifications, or braces that may be prescribed for these conditions. In this article, we will summarize the orthoses used for treatment of the most commonly encountered foot and ankle pathologies, with the exclusion of treatment for the diabetic foot because of the unique requirements of that disease process.

"In Situ" Joint Preparation Technique for First Metatarsophalangeal Arthrodesis: A Retrospective Comparative Review of 388 Cases.

"Cup-shaped power reamers" and "flat cuts" (FC) are common joint preparation techniques in first metatarsophalangeal (MTP) joint arthrodesis. However, the third option of an "in situ" (IS) technique has rarely been studied. This study aims to compare the clinical, radiographic, and patient-reported outcomes (PROMs) of the IS technique for various MTP pathologies with other MTP joint preparation techniques. A single-center retrospective review was performed for patients who underwent primary MTP joint arthrodesis between 2015 and 2019. In total, 388 cases were included in the study. We found higher nonunion rates in the IS group (11.1% vs 4.6%, p = .016). However, the revision rates were similar between the groups (7.1% vs 6.5%, p = .809). Multivariate analysis revealed that diabetes mellitus was associated with significantly higher overall complication rates (p < .001). The FC technique was associated with transfer metatarsalgia (p = .015) and a more first ray shortening (p < .001). Visual analog scale, PROMIS-10 physical, and PROMIS-CAT physical scores significantly improved in IS and FC groups (p < .001, p = .002, p = .001, respectively). The improvement was comparable between the joint preparation techniques (p = .806). In conclusion, the IS joint preparation technique is simple and effective for first MTP joint arthrodesis. In our series, the IS technique had a higher radiographic nonunion rate that did not correlate with a higher revision rate, and otherwise similar complication profile to the FC technique while providing similar PROMs. The IS technique resulted in significantly less first ray shortening when compared to the FC technique.

High complication rates following revision first metatarsophalangeal joint arthrodesis: a retrospective analysis of 79 cases.

BACKGROUND: The most common indications for revision of first metatarsophalangeal joint (MTPJ) arthrodesis are symptomatic failures of prior arthrodesis, failed hallux valgus correction, and failed MTPJ arthroplasty implants. However, the outcomes of revision MTPJ arthrodesis have rarely been studied. The purpose of this study was to compare the clinical, radiographic, and patient-reported outcomes of revision MTPJ arthrodesis following different primary procedures. METHODS: A retrospective review of revision MTPJ arthrodesis cases between January 2015 and December 2019 was performed. The radiographic results, patient-reported outcomes, and rates of complications, subsequent revisions, and nonunions, were analyzed and compared preoperatively and postoperatively. A multivariate analysis was utilized to determine risk factors for complications and reoperations. RESULTS: This study yielded a total of 79 cases of revision MTPJ arthrodesis. The mean follow-up time was 365 days (SD ± 295). The overall complication rate was 40.5%, of which the overall nonunion rate was 19.0%. Seven cases (8.9%) required further revision surgery. The multivariate analysis revealed that Diabetes mellitus was associated with significantly higher overall complication rates (p = 0.016), and nonunion was associated with "in-situ" joint preparation techniques (p = 0.042). Visual Analog Scale (VAS) significantly improved postoperatively (p < 0.001); However, PROMIS-10 physical health and PROMIS-10 mental health did not change significantly during the study period. CONCLUSION: Treatment of MTPJ surgery failures is a clinical challenge in orthopedic surgery. In our study, revision of first MTPJ surgery resulted in higher nonunion rates and overall complication rates compared to typical outcomes from primary MTPJ arthrodesis. Diabetes, Tobacco use, and "in-situ" joint preparation technique were found to be independent risk factors for complications and reoperations. LEVEL OF EVIDENCE: III-Retrospective Cohort Study.

Patient Satisfaction Following Hallux Rigidus Treatment With a Synthetic Cartilage Implant.

BACKGROUND: There remains no clear consensus on patient satisfaction and functional outcomes following synthetic cartilage implant (SCI) implantation for hallux rigidus. The purpose of this study was to review our experience at a single academic institution using an SCI for treatment of hallux rigidus. METHODS: A retrospective review was performed of patients who underwent the SCI procedure for treatment of hallux rigidus between January 2017 and May 2019. Functional outcomes were evaluated using Patient-Reported Outcome Measures Informational System (PROMIS)-10 scores as well as a survey investigating patient satisfaction, self-reported clinical improvement, and changes in sporting ability. Patients were divided into satisfied versus unsatisfied subgroups, and between-group differences in preoperative variables and complications were reviewed. A total of 90 patients (96 implants) were included in this study. The mean follow-up time was 26.4 months. RESULTS: In all, 81.2% of patients reported that their foot was "much improved" (55.2%) or "improved" (26.0%) since undergoing the SCI procedure, whereas a slightly lower percentage, 74.0%, stated that they were "extremely satisfied" (41.7%) or "satisfied" (32.3%) at final follow-up. Patients were able to tolerate higher impact sporting activities after the procedure, and 75.0% of patients stated they would have the same surgery again. PROMIS-10 T-scores averaged 54.2 points for physical health and 57.4 points for mental health. Only 2.1% of patients required conversion to arthrodesis. Significant differences between the satisfied versus unsatisfied subgroups were found in preoperative corticosteroid injection use (21.1% vs 41.1%, respectively; P = .029) and preoperative VAS pain score (8.2 vs 7.1, respectively; P = .036). CONCLUSION: The SCI procedure can be a viable option for treating hallux rigidus with high satisfaction overall, increased sport activity levels, and a very low revision rate. However, maximizing patient satisfaction may require more careful consideration of preoperative prognosticators and extensive patient counseling to ensure realistic expectations for recovery time and individual outcome. LEVEL OF EVIDENCE: Level IV: Retrospective case series.

Midfoot Joint Arthrodesis Using Compression Plate With Lag Screw Augmenting With Highly Porous ß-Tricalcium Phosphate and Bone Marrow Aspirate Concentrate.

BACKGROUND: There is still a controversy regarding the most optimal fixation instruments and bone graft materials for midfoot joint arthrodesis. We present the results of midfoot joint arthrodesis using compression plate with lag screw augmenting with highly porous ß-tricalcium phosphate (ß-TCP) and bone marrow aspirate concentrate (BMAC). METHODS: We performed a retrospective review of patients undergoing midfoot joint arthrodesis using compression plate with lag screw augmenting with highly porous ß-TCP and BMAC from January 2014 to May 2019. The radiographic bony union rate was investigated. Postoperative complications and reoperations were also reviewed. A total of 36 patients (37 feet) including 75 joints were available in this study. RESULTS: A high union rate was achieved as of 97.3% in 73 of 75 joints. Nonunion occurred in 2 patients including 2 joints. Other than nonunion, there were no major complications such as deep infection. Minor complications (5 of 75 joints, 6.7%) included hardware irritations. Reoperations were required in 1 patient for revision of arthrodesis and symptomatic hardware removal was performed in all 5 hardware irritation cases. CONCLUSION: Based on our results, the fixation construct of compression plate with lag screw augmenting with highly porous ß-TCP and BMAC is safe and effective for midfoot joint arthrodesis with an excellent union rate and a low complication rate. LEVEL OF EVIDENCE: IV, retrospective case series.

Adverse Events Related to Cartiva Hemiarthroplasty of First Metatarsal: An Analysis of Reports to the United States Food and Drug Administration.

Background: The results supporting Cartiva, a synthetic cartilage implant (Wright Medical) in hallux rigidus have come from limited institutions creating observational bias. Complications experienced in community centers are not routinely included in the published literature. To look at a broader range of potential complications, we reviewed the United States Food and Drug Administration's (FDA) voluntary device database and compared that data with published literature. Methods: The Manufacturer and User Facility Device Experience (MAUDE) database of the FDA was retrospectively reviewed between July 2016 and October 2019 using the product code: PNW, assigned for Cartiva. Results: A total of 49 events have been reported and implant subsidence was the most common with 16 reports. Others include fragmentation (9), infection (4), bone erosion (3), foreign body reaction (1) and unspecified (16). Thirty-five events mentioned further surgeries at a mean interval of 4.75 months. Conclusions: The analysis of the MAUDE database disclosed certain device-related dysfunctions that have been underreported in the published literature. Because of the voluntary nature of reporting, the true incidence of each complication is unknown with this data representing a baseline. The MAUDE database could be further strengthened by a more robust reporting mechanism or mandatory reporting of device-related complications.Levels of Evidence: Level IV: Case series from large database analysis.

Comparison of 4 Different Fixation Strategies for Midfoot Arthrodesis: A Retrospective Comparative Study.

BACKGROUND: Midfoot arthrodesis is a common procedure performed both for arthritis and correction of deformity. The optimal fixation for midfoot arthrodesis has not been established, though numerous studies have been investigating the fixation techniques of midfoot arthrodesis. The purpose of this study was to compare the union rate of midfoot arthrodesis using 4 different fixation strategies and investigate risk factors of nonunion following midfoot arthrodesis. METHODS: A retrospective chart review was performed for patients who underwent midfoot joint arthrodesis between January 2014 and May 2019. The rates of nonunion and postoperative complication were compared among 4 different fixation constructs: staple fixation, compression plate fixation, compression plate with lag screw fixation, and compression screw fixation. Predictors of nonunion following midfoot arthrodesis were investigated through a multivariable logistic regression analysis. A total of 95 patients (99 feet), including 240 midfoot joints were included in this study. The mean follow-up period was 78.4 weeks. RESULTS: Overall, bony union was achieved in 86 out of 99 (86.9%) patients, which included 218 out of 240 (90.8%) midfoot joints. A significant difference in the nonunion rate according to the type of fixation construct was found (P = .011); the compression screw alone fixation construct was noted to have a significantly higher nonunion rate than other fixation constructs. Diabetes mellitus (odds ratio [OR] = 0.179 [95% CI: 0.059, 0.542]), the type of fixation construct (compression screw alone; OR =1.789 [95% CI: 1.071, 2.978]), lack of adjuvant bone graft (OR = 2.803 [95% CI: 1.081, 7.268], and postoperative nonanatomical alignment (OR = 3.937 [95% CI: 1.278, 12.126]) were identified as independent predictors of nonunion following midfoot arthrodesis. CONCLUSION: The rate of nonunion following midfoot arthrodesis among 4 different commonly used fixation constructs was compared in this study. Risk factors of nonunion were investigated revealing that diabetes mellitus, compression screw fixation alone, lack of adjuvant bone graft, and postoperative nonanatomical alignment are independent predictors of nonunion following midfoot arthrodesis. LEVELS OF EVIDENCE: Level III: Comparative cohort study.

A Retrospective Radiographic Evaluation of a Modified Method of Lateral Column Lengthening.

Background: Lateral column lengthening (LCL) is a commonly performed procedure for patients with stage II adult-acquired flatfoot deformity (AAFD) to correct forefoot abduction. This procedure is frequently completed concomitantly with both soft-tissue and bony procedures, including a medial slide calcaneal osteotomy to further reduce hindfoot valgus. The purpose of this study is to investigate and identify the radiographic outcomes of a modified step-cut LCL utilized as an alternative approach for correction of stage II AAFD. Methods: A retrospective radiographic review was performed on 15 feet in 14 patients who underwent correction of stage II AAFD using a step-cut LCL between August 2009 and January 2012. Two independent examiners utilizing 6 radiographic parameters evaluated preoperative and postoperative weight-bearing radiographs of the foot. Results: At a mean follow-up of 13.4 (range 12-16) weeks, weight-bearing radiographs demonstrated a significant median decrease in the lateral talometatarsal angle of 14.4° (P < .001), lateral talocalcaneal angle of 7° (P < .001), anteroposterior talometatarsal angle of 14.5° (P < .001), anteroposterior talocalcaneal angle of 5.5° (P < .001), and talonavicular coverage angle of 26.5° (P < .001). Additionally, a significant median increase in calcaneal pitch of 8.5° (P < .001) was noted. Conclusion: This study demonstrates statistically significant improvement of radiographic outcomes with use of a modified step-cut LCL as an alternative approach for correction of stage II AAFD.Levels of Evidence: Level IV: Retrospective case series.

A Case Report of Bilateral Navicular Osteonecrosis Successfully Treated With Medial Femoral Condyle Vascularized Autografts: A Case Report.

CASE: A 17-year-old boy with a history of chronic bilateral navicular osteonecrosis with fragmentation was treated with 6-month staged bilateral open reduction and internal fixation of tarsal navicular with debridement of the necrotic bone and ipsilateral medial femoral condyle vascularized bone grafting. CONCLUSION: The patient progressed to full painless weight-bearing on each extremity by 4 months postoperatively with osseous union of both chronic fracture sites and incorporation of vascularized bone grafts. Patient-Reported Outcomes Measurement Information System (PROMIS) scores were improved from preoperative levels at 6 months from each operation. This patient's atypical presentation of a rare disease was successfully treated with the utilization of vascularized bone grafting to salvage the tarsal navicular and preserve the talonavicular joint, enabling return of function and avoidance of early arthrodesis procedure.

Medial Femoral Condyle Free Flap Reconstruction of Complex Foot and Ankle Pathology.

BACKGROUND: Complex hindfoot pathology may benefit from vascularized bone flap reconstruction rather than traditional bone grafting techniques. Medial femoral condyle (MFC) flaps provide vascularized periosteum, skin, and corticocancellous bone. METHODS: A retrospective, single-institution cohort study of consecutive MFC flaps performed for complicated hindfoot reconstruction between 2013 and 2019 was reviewed. Radiologic follow-up assessed osseous union and clinical outcomes were evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score. Thirty MFC flaps were performed in 28 patients for complex hindfoot pathology. Twenty-seven flaps had adequate clinical and radiographic follow-up (mean 15.8 months). RESULTS: The majority presented with avascular necrosis (83%) and failed prior operations (67%, mean 3.1). Most hindfoot procedures involved arthrodesis (n = 24, 80%); tibiotalocalcaneal (n = 11) and talonavicular (n = 7) most frequently. Mean osseous flap volume was 10.3 cm3 (range 1.7-18.4 cm3); one flap required takeback for venous congestion but no total flap losses occurred. Primary osseous union was initially achieved in 20 patients (74%, mean 217 days). Six flaps developed interface nonunion; 5 underwent revision arthrodesis and ultimately achieved union in 24/27 flaps (89%, mean 271 days). Risk factors for nonunion were body mass index (BMI) >30 (P = .017) and prior arthrodesis (P = .042). Mean AOFAS hindfoot scores increased significantly from 52.3 preoperatively to 70.7 postoperatively (P < .001). Subscore analysis demonstrated significant improvement in postoperative pain scores from 14.2 to 27.3 out of 40 (P < .001). CONCLUSION: The MFC free flap provided vascularized bone for complicated foot and ankle reconstruction with relatively low donor site morbidity, promising osseous union results, and improved functional outcomes. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Ankle Arthrodesis with Free Vascularized Fibula Autograft Using Saphenous Vein Grafts: A Case Series.

BACKGROUND: In select high-risk cases of ankle arthrodesis, conventional techniques may lead to a high incidence of failure because of a combination of multiple operations; high risk of infection; avascular, often bulky allografts; and poor soft-tissue quality. In high-risk distal limb salvage, the authors have performed ankle arthrodesis using a free vascularized fibula graft from the ipsilateral limb with saphenous vein grafts. METHODS: The authors present data from six patients. The cause of the defect was avascular necrosis of the talus (n = 4), osteomyelitis (n = 1), and failed total ankle replacement (n = 1). The ipsilateral fibula was used in all cases as a free vascularized graft. Nonviable bone and soft tissue were débrided, and the fibula was shortened to size and impacted into the cavitary space spanning the distance between the tibia, talus, and calcaneus. The pedicle distally was anastomosed to saphenous vein grafts and proximally anastomosed to the divided peroneal vessels. RESULTS: The flap success rate was 83 percent (n = 5). The complication rate was 83 percent; complications included flap loss (intraoperative arterial thrombosis), loss of skin island, hematoma, and arterial thrombosis. Despite one flap failure and a high complication rate, successful union was obtained in all patients. All patients achieved full weight-bearing status by a mean of 4 months after surgery (range, 3 to 7 months). There were no amputations. CONCLUSIONS: Vascularized free fibula graft is a reliable option for ankle arthrodesis in complex salvage situations. Using a saphenous vein graft to perform the anastomosis with the divided peroneal vessels proximally should be considered.

Anatomical feasibility study of flexor hallucis longus transfer in treatment of Achilles tendon and posteromedial portal of ankle arthroscopy.

PURPOSE: The aim of this study was to evaluate the occurrence of anatomical variations of the musculotendinous junction of the flexor hallucis longus (FHL) muscle, the relationship between FHL tendon or muscle and the tibial neurovascular bundle at the level of the posterior ankle joint in human cadavers. METHODS: Seventy embalmed feet from 20 male and 15 female cadavers, the cadavers' mean age was 65.4 (range from 14 to 82) years, were dissected and anatomically classified to observe FHL muscle morphology define the relationship between FHL tendon or muscle and the tibial neurovascular bundle. The distance between the musculotendinous junction and the relationship between FHL tendon or muscle and the tibial neurovascular bundle was determined. RESULTS: Three morphology types of FHL muscle were identified: a long lateral and shorter medial muscle belly, which was observed in 63 specimens (90%); equal length medial and lateral muscle bellies, this variant was only observed in five specimens (7.1%); one lateral and no medial muscle belly, which was observed in two specimens (2.9%). No statistically significant difference was observed according to gender or side (p > 0.05). Two patterns were identified and described between FHL tendon or muscle and the tibial neurovascular bundle. Pattern 1, the distance between the neurovascular bundle and FHL tendon was 3.46 mm (range 2.34-8.84, SD = 2.12) which was observed in 66 specimens (94.3%); Pattern 2, there was no distance which was observed in four specimens (5.7%). CONCLUSION: Knowing FHL muscle morphology, variations provide new important insights into secure planning and execution of a FHL transfer for Achilles tendon defect as well as for the interpretation of ultrasound and magnetic resonance images. With posterior arthroscopic for the treatment of various ankle pathologies, posteromedial portal may be introduced into the posterior aspect of the ankle without gross injury to the tibial neurovascular structures because of the gap between the neurovascular bundle and FHL tendon.

Prevalence and orthopedic management of foot and ankle deformities in Charcot-Marie-Tooth disease.

INTRODUCTION: Foot deformities are frequent complications in Charcot-Marie-Tooth disease (CMT) patients, often requiring orthopedic surgery. However, there are no prospective, randomized studies on surgical management, and there is variation in the approaches among centers both within and between countries. METHODS: In this study we assessed the frequency of foot deformities and surgery among patients recruited into the Inherited Neuropathies Consortium (INC). We also designed a survey addressed to orthopedic surgeons at INC centers to determine whether surgical approaches to orthopedic complications in CMT are variable. RESULTS: Foot deformities were reported in 71% of CMT patients; 30% of the patients had surgery. Survey questions were answered by 16 surgeons working in different specialized centers. Most of the respondents were foot and ankle surgeons. There was marked variation in surgical management. DISCUSSION: Our findings confirm that the approaches to orthopedic management of CMT are varied. We identify areas that require further research. Muscle Nerve 57: 255-259, 2018.

Anatomical Study of the Neurovascular in Flexor Hallucis Longus Tendon Transfers.

The transfer of the flexor hallucis longus tendon or flexor digitorum longus tendon is frequently used for the treatment of posterior tibial tendon insufficiency or chronic Achilles tendinopathy. According to several anatomical studies, harvesting the flexor hallucis longus (FHL) tendon may cause nerve injury. Sixty-eight embalmed feet were dissected and anatomically classified to define the relationship between Henry's knot and the plantar nerves. Two different configurations were identified. In Pattern 1, which was observed in 64 specimens (94.1%), the distance between the medial plantar nerve and Henry's knot was 5.96 mm (range, 3.34 to 7.84, SD = 1.12). In Pattern 2, which was observed in 4 specimens (5.9%), there was no distance between the medial plantar nerve (MPN) and Henry's knot. No statistically significant difference was observed according to gender or side (p > 0.05). A retraction was performed to harvest the FHL through the posteromedial hindfoot incision using a single minimally invasive technique, and the medial and lateral plantar nerve lesions were scrupulously assessed. In conclusion, medial and lateral plantar nerve injuries did not occur more frequently, even after performing a single minimally invasive incision to harvest the FHL tendon, due to the large distance between the FHL tendon and the medial and lateral plantar nerves.

The anatomy and clinical applications of flexor hallucis longus tendon transfer in treatment of chronic Achilles tendinopathy / 中华显微外科杂志

Objective To evaluate the effectiveness of flexor hallucis longus tendon transfer in treatment of chronic Achilles tendinopathy using different technique.Methods Sixty-four embalmed feet of 32 cadavers were analyzed and classified anatomically with respect to the individual cross links in the Henry's knot.These three techniques were then combined to determine the total potential tendon graft length obtainable using single incision,double incision and minimally invasive incision.From January,2012 to June,2015,10 patients (10 feet) with chronic Achilles tendinopathy were treated with double incision technique.The score was 63.04 ±7.75 according to American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score system.Results Only two different configurations were found.Type 1,a tendinous slip branched from the FHLT to the FDLT was 96.9％(62 of 64 feet).Type 2,a slip branched from the FHLT to the FDLT and another slip from the FDLT to FHLT was 3.1％(2 of 64).The average length of the FHLT graft available from a single incision measured (5.08±1.09)cm,double incision technique measured (6.72 ± 1.02) cm,and minimally invasive incision measured (17.49 ± 1.80)cm.The difference between the lengths obtained from these three techniques was statistically significant.Ten patients were followed-up 12-36 months (mean,13.7 months).At 12 months after operation,the AOFAS ankle and hindfoot score was 93.28 ± 3.72,showing significant difference when compared with that before operation.The results were excellent in 6 cases,good in 3 cases,and fair in 1 case with an excellent and good rate of 90％.No sural nerve injury,posterior tibial nerve injury,medial plantar nerve injury,and lateral plantar nerve injury occurred.Conclusion In over 96 ％ of the feet,a proximal to distal connection from the FHLT to the FDLT was found,which might contribute to the residual function of the lesser toes after FDLT transfer.The distal stump of the FHLT tendon should be sutured onto the FDLT tendon under tension to en able a co-activation of the great toe,preserved hallux plantar flexion.Chronic Achilles tendinopathy reconstruction with flexor hallucis longus tendon harvested using double incision technique offers a desirable outcome in operative recovery,tendon fixation,preserved hallux plantar flexion and less complications.

Anatomical study for flexor hallucis longus tendon transfer in treatment of Achilles tendinopathy.

PURPOSE: The purpose of the study was to describe the anatomical variations of the connection between the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendons in the knot of Henry in Asians, and quantify the length of FHL tendon graft with different incisions. METHODS: Sixty-four embalmed feet of 32 cadavers were analyzed anatomically with respect to the individual cross-links in the planta pedis. Single incision technique graft length was measured from the musculotendinous junction of FHL and the point at sustentaculum tali. Double incision technique was measured from musculotendinous junction of FHL and the level of the master knot of Henry. Additionally, minimally invasive incision technique was measured from musculotendinous junction of FHL to the first interphalangeal joint. These three techniques were then combined to determine the total potential tendon graft length obtainable using different approach. RESULTS: Only two different configurations were found. Type 1, a tendinous slip branched from the FHL to the FDL (62 of 64 feet). Type 2, a slip branched from the FHL to the FDL and another slip from the FDL to FHL (2 of 64). The average length of the FHL graft available from a single incision measured 5.08 cm (range 3.32-10.35, SD = 1.09), double incision technique measured 6.72 cm (range 4.69-12.09, SD = 1.03), and minimally invasive incision measured 17.49 cm (range 13.51-20.52, SD = 1.80). The difference between the lengths obtained from these three techniques was statistically significant (p < 0.001). CONCLUSION: The absence of no attachment and FDL tendon to the FHL between the two tendons in the foot may be more frequent than previously reported. Only two configurations of the anatomical relationship were found in this study. In over 96 % of the feet, a proximal to distal connection from the FHL to the FDL was found, which might contribute to the residual function of the lesser toes after FDL transfer.

The proximal crescentic osteotomy of the first metatarsal bone combined distal soft tissue reconstruction to treat severe hallux valgus / 中华整形外科杂志

<p><b>OBJECTIVE</b>To explore the method of the treatment for hallux valgus with the proximal crescentic osteotomy of the first metatarsal bone, combining with distal lateral soft tissue release.</p><p><b>METHODS</b>From January 2008 to December 2012, 21 cases 21 hallux valgus feet were treated by operative procedure, included 1 male (1 foot) and 20 females (20 feet), with the mean age of 52 years (range, 36-68 years). Among all patients were followed up for 12 to 26 months, with the mean 16 months. The preoperative, post-operative and final follow-up X-ray films of all patients were collected. The hallux valgus angle, intermetatarsal angle and distal metatarsal articular angle were measured and analyzed. The surgical outcome was evaluated combined with the AOFAS score.</p><p><b>RESULTS</b>The average hallux valgus angle decreased from 42.3° ± 1.8° preoperatively to 14.5° ± 1.8 postoperatively, the average intermetatarsal angle did from 21.9° ± 1.7 to 9.1° ± 1.8°, and the average distal metatarsal articular angle did from 14.9° ± 1.8 to 7.2° ± 1.5, respectively. There were significant differences between the preoperative and postoperative roentgenographic index. AOFAS score was improved from 44.0 ± 1.8 preoperatively to 83.9 ± 2.2 at the final follow-up.</p><p><b>CONCLUSIONS</b>The proximal crescentic osteotomy of the first metatarsal bone combined distal soft tissue reconstruction obtained satisfactory results in severe hallux valgus patients with big intermetatarsal angle.</p>

Tendon progenitor cells in injured tendons have strong chondrogenic potential: the CD105-negative subpopulation induces chondrogenic degeneration.

To study the cellular mechanism of the tendon repair process, we used a mouse Achilles tendon injury model to focus on the cells recruited to the injured site. The cells isolated from injured tendon 1 week after the surgery and uninjured tendons contained the connective tissue progenitor populations as determined by colony-forming capacity, cell surface markers, and multipotency. When the injured tendon-derived progenitor cells (inTPCs) were transplanted into injured Achilles tendons, they were not only integrated in the regenerating area expressing tenogenic phenotype but also trans-differentiated into chondrogenic cells in the degenerative lesion that underwent ectopic endochondral ossification. Surprisingly, the micromass culture of the inTPCs rapidly underwent chondrogenic differentiation even in the absence of exogenous bone morphogenetic proteins or TGFßs. The cells isolated from human ruptured tendon tissues also showed connective tissue progenitor properties and exhibited stronger chondrogenic ability than bone marrow stromal cells. The mouse inTPCs contained two subpopulations one positive and one negative for CD105, a coreceptor of the TGFß superfamily. The CD105-negative cells showed superior chondrogenic potential in vitro and induced larger chondroid degenerative lesions in mice as compared to the CD105-positive cells. These findings indicate that tendon progenitor cells are recruited to the injured site of tendons and have a strong chondrogenic potential and that the CD105-negative population of these cells would be the cause for chondroid degeneration in injured tendons. The newly identified cells recruited to the injured tendon may provide novel targets to develop therapeutic strategies to facilitate tendon repair.

Reconstruction of great toe soft-tissue defect with the retrograde-flow medial pedis island flap.

BACKGROUND: Several investigators have reported their clinical experience with medial pedis flaps for reconstruction of soft-tissue defects of the distal forefoot. However, they had only a few reports where this flap was used to repair soft-tissue defects of the great toe. Thus, reconstruction of soft-tissue defects of the great toe remains a challenge in reconstructive surgery. The authors describe the use of the medial pedis island flap to cover this region. METHODS: This study was divided into two parts: an anatomic study and clinical application. In the anatomic study, 48 cadaveric feet were injected with latex, and then the main vessels distributed at the medial aspect of the foot were observed. Clinically, retrograde-flow medial pedis island flaps were harvested to cover the soft-tissue defects of the great toe in eight cases. RESULTS: An anatomic study revealed that the arterial circle under the first metatarsophalangeal joint and the arterial network on the surface of the abductor hallucis were responsible for the blood supply of the medial region of the foot. The diameter of the pedicle was great, and the pedicle was longer than previously reported. In terms of clinical application, all flaps were successful, without any significant complications. CONCLUSIONS: Using the arterial circle under the first metatarsophalangeal joint, the medial pedis island flap has a reliable retrograde blood supply. This flap should be considered as a preferential way of reconstructing soft-tissue defects of the great toe. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.