Intramedullary screw fixation of proximal fifth metatarsal fractures: a biomechanical study.

Intramedullary screw fixation is a popular technique for treatment of proximal fifth metatarsal fractures. The purpose of this study was to compare the fixation rigidity of a 5.5 mm partially threaded cannulated titanium screw, with presumed superior endosteal purchase, to a similar 4.5 mm screw. Acute fifth metatarsal fractures were simulated in cadavers, stabilized with intramedullary screws, and loaded to failure in three-point bending. The initial failure loads for the metatarsals fixed with 4.5 mm and 5.5 mm screws were not significantly different (332.4 N vs. 335.2 N, respectively), nor were the ultimate failure loads (849.8 N vs. 702.2 N, respectively). Based upon our results, maximizing screw diameter does not appear to be critical for fixation rigidity and may increase the risk of intraoperative or postoperative fracture.

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.

Disorders of the first metatarsophalangeal joint: diagnosis of great-toe pain.

Disorders of the joint at the base of the hallux are common in active patients. Great-toe sprains (turf toe) can range from mild to severe with associated fractures. Hallux rigidus, a painful flexion deformity, is often seen in athletes who stress the joint repetitively. Heredity may predispose athletes to hallux valgus (bunion) but improper footwear, injury, and hyperpronation can also be implicated. Weight-bearing activities, climbing stairs, or wearing high-heeled shoes will aggravate sesamoiditis. Stress fractures, osteochondral defects, and gout are other causes of toe pain. X-rays are essential for accurate diagnosis. Nonoperative measures can reduce pain, but surgery is an option for recalcitrant cases.

Biplanar chevron osteotomy.

We retrospectively reviewed the results of using a biplanar chevron osteotomy performed on patients who presented with hallux valgus deformities with an increased distal metatarsal articular angle (DMAA). The study included 17 feet (14 patients) of 12 women and 2 men. The average follow-up was 33 months. The average American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Clinical Rating Score was 91. Ten of the 14 patients (13 of 17 feet) stated that they would choose to undergo the procedure again. The hallux valgus angle was improved from an average of 22 degrees to 18 degrees, the intermetatarsal angle from 11 degrees to 9 degrees, and the DMAA from 16 degrees to 9 degrees. We have demonstrated this procedure to be useful in the treatment of symptomatic bunion deformities with an increased DMAA.

Prosthetic survival and clinical results with use of large-segment replacements in the treatment of high-grade bone sarcomas.

We evaluated the long-term clinical results and the survival of the prostheses in eighty-two patients who had had a limb-sparing procedure by means of the implantation of a large-segment prosthesis. All patients had had a high-grade bone sarcoma of the distal, middle, or proximal part of the femur; the proximal part of the humerus; the proximal part of the tibia; or the pelvis. The duration of follow-up ranged from two to twelve years (median, three and one-half years). Function was evaluated with the revised 30-point classification system of the Musculoskeletal Tumor Society. The survival of the prostheses was analyzed with regard to several variables with use of Kaplan-Meier survival estimates. Sixty-eight patients were alive at the latest follow-up evaluation. The survival rate of the prostheses was 83 per cent at five years and 67 per cent at ten years. Twelve prostheses were revised, and eleven revisions were successful. The rate of revision was highest (six of thirteen) in the patients who had had a tumor of the proximal part of the tibia. In contrast, only three (10 per cent) of the thirty-one patients who had had a tumor of the distal part of the femur and three (10 per cent) of the twenty-nine who had had a tumor of the proximal part of the humerus had a revision. Eleven patients (13 per cent) had an infection, which necessitated an amputation in six. Five patients (6 per cent) had a local recurrence, and nine patients (11 per cent), including the six already mentioned, ultimately needed an amputation. Patients who had had a tumor of the proximal part of the humerus had the highest functional scores, while those who had had a tumor of the proximal part of the tibia had the lowest scores. Large-segment prostheses were a good reconstructive option for the treatment of high-grade bone sarcomas in our patients. The rates of long-term survival of the prostheses were acceptable and the functional results were good or excellent after this form of treatment at most of the anatomical sites at which they were used.

Tibiocalcaneal arthrodesis.

A review of eight patients who underwent nine tibiocalcaneal arthrodeses was performed. The surgical indications were failed previous surgery, posttraumatic talar avascular necrosis, and rheumatoid arthritis. The average age at the time of operation was 54 years. The average time of follow-up was 40 months after the operation. Fusion was achieved in all nine feet, with an average time of fusion of 5 months. Results were excellent in three feet, good in four feet, fair in one foot, and poor in one foot. The average leg length discrepancy was 2 cm. The average position of fusion was 6 degrees of valgus and 2 degrees of plantarflexion. All patients stated that they had improvement of pain and function. Seven of the eight patients stated that they would have the procedure done again. Complications were local infection in two patients, malunion in two patients, wound slough in one patient, and a prominent fibula in one patient. Tibiocalcaneal arthrodesis should be reserved as a salvage procedure because it is technically difficult and has a significant risk of complications.

Surgical management for intractable metatarsalgia.

We reviewed the results of arthrodesis of the first metatarsophalangeal joint and excisional arthroplasty of the lesser metatarsophalangeal joints performed on patients who presented intractable metatarsalgia and forefoot deformities. The study included 18 feet (15 patients) in 12 women and 3 men. The follow-up averaged 5.2 years. A good to excellent result was achieved in 15 (83%) feet; pain, which had been moderate to severe before surgery, was reduced to none to mild, and function, which had been severely limited before surgery, was improved to virtually unlimited. The fusion rate of the first metatarsophalangeal joint was 94% (17 of 18 feet). Thirteen of the 15 patients (87%) stated they would have the procedure again. This repair has been demonstrated to be a useful salvage procedure in nonrheumatoid patients with severe metatarsalgia secondary to failed forefoot surgery.

Open-reduction and intertrochanteric osteotomy for osteonecrosis and extrusion of the femoral head in adolescents.

Extrusion of the femoral head during late childhood and adolescence can be caused by tissue interposition following traumatic hip dislocation, inflammatory joint disease, or avascular necrosis with flattening of the femoral head. We report our experience of treatment by reorientation of the extruded femoral head with combined open-reduction and intertrochanteric osteotomy in seven young patients with Ficat stage III or IV avascular necrosis. Six of the seven patients showed improvement of pain and limp. They also had radiographic improvement of joint space and congruency, which suggests that the degenerative process and further surgery may be delayed.

Analysis of surgical treatment of 33 foot and ankle tumors.

Thirty-three patients treated for tumors of the foot and ankle at one cancer institution over a 14-year period were reviewed. There were 15 females and 18 males, with an age range of 1 to 64 years (average 22.6 years). Twenty-one tumors were benign, 11 were malignant, and 1 tumor had metastasized. The most common diagnoses were: fibromatosis (10), aneurysmal bone cyst (4), synovial sarcoma (4), chondrosarcoma (3), and other (12). Surgical procedures included: wide resection (14), local resection (8), curettage and cryosurgery (7), and below-knee amputation (4). Follow-up from surgery was 1 to 13 years (average 7.2 years). There were no local recurrences. Functional results were good-to-excellent in 82% (27/33) of patients. Fifty-five percent (18/33) of the patients were full weightbearing and enjoyed unlimited activity.