A Simplified Preoperative Radiographic Assessment for Metatarsus Adductus Associated With Hallux Valgus.

Radiographic measurements for the assessment of metatarsus adductus (MTA) have a broad range of interpretation without a consensus regarding surgical indications. The "Plumbline" (PL) radiographic assessment method helps identify MTA and determines if physical space is available to align the first metatarsal to the longitudinal foot axis without the need to realign the lesser metatarsals. Forty-five neutral weight-bearing anterior-posterior (AP) radiographs of patients scheduled for surgical intervention for isolated hallux valgus (HV) or combined MTA/HV deformities were reviewed. The cohort was grouped based on the presence of MTA using a Sgarlato's angle (SA) of 15°, with 23 patients in the HV-only group and 22 patients in the MTA group. A mean preoperative SA of 8.7° (SD: 2.1; range: 5.4-13.4) and 26.6° (SD: 5.1; range: 18.2-36) were found in the HV-only and MTA groups, respectively. Subjects with an SA ≤ 15° (N = 22) were found to have a negative PL (100%) and subjects with an SA > 15° (N = 23) displayed a positive PL (100%). The PL technique provided a simple method and clear visual reference for determining the presence of MTA in HV patients without the need to measure traditional radiographic angles.Level of Evidence: Retrospective, Level IV, Diagnostic.

What Do Patients Report Regarding Their Real-World Function Following Concurrent Arthrodesis of the First Tarsometatarsal and First Metatarsophalangeal Joints.

First metatarsal phalangeal joint and the first Tarsometatarsal arthrodesis have both been used for deformity correction and treatment of pain and arthritis. Concomitant arthrodesis of the first metatarsophalangeal and first tarsometatarsal joints (Double First Ray Arthrodesis) has rarely been described. We surveyed 29 patients who underwent double first-ray arthrodesis for primary or revision correction of hallux valgus. A custom questionnaire was used to assess their activities of daily living and sports activity at a mean follow-up of 19.6 months (median 18.4 months). Secondary endpoints were return to activity, deformity correction, and arthrodesis healing rate. The primary outcomes showed an excellent return to activities of daily living with 96.6% of patients capable of walking as much as they liked after surgery at a normal pace. About 96.6% reported they felt that their surgery was successful, they had no pain, and the loss of motion at the joint fusion sites did not affect their ability to perform daily activities. Protected walking in a fracture boot was initiated at a mean (SD) of 9.8 (9.9) days. Return to an athletic shoe occurred at a mean (SD) of 44.2 (11.7) days. Full unrestricted activity was at a mean (SD) of 105.2 (19.3) days with 65% of the patient group reporting that their recovery was easier than expected. There was 1 nonunion and no other complications. This data set supports the hypothesis that patients undergoing double first-ray arthrodesis can return to activities of daily living and sports with and low complication rate.

Lapidus Arthrodesis.

There has been significant enhancement in surgical management of hallux valgus deformity. Recognition of the role of medial column hypermobility has resulted in better functional outcomes with decreased risk of recurrence. Modern techniques have evolved to include enhanced fixation in a move toward minimal postoperative downtime. Evolution to include true triplane correction, including frontal plane derotation of the first ray, has resulted in optimal functional outcomes. The addition of anatomic triplane restoration, enhanced internal fixation, and early return to weight-bearing activities are combined resulting in lifelong correction with excellent functional outcomes and a high degree of patient satisfaction.

Soft Tissue Reconstruction and Osteotomies for Pes Planovalgus Correction.

The correction of the flexible pes planovalgus foot and ankle is a complicated and somewhat controversial topic. After conservative methods fail, there is a wide range of possible soft tissue and bony procedures. The appropriate work up and understanding of the pathomechanics are vital to the correct choice of procedures to correct these deformities. Once the work up and procedure selection are done, the operation must also be technically performed well and with efficiency, as most often the condition is corrected with a variety of procedures. This article discusses some of the most common procedures necessary to fully correct the pes planovalgus foot and discusses the authors' technique and pearls.

A Systematic Approach to the Surgical Correction of Combined Hallux Valgus and Metatarsus Adductus Deformities.

The presence of metatarsus adductus (MTA) adds complexity to the diagnosis and treatment of hallux valgus (HV). Identification and careful analysis of these combined deformities is of paramount importance. The inability to completely correct HV and an increased incidence of recurrence has been established when MTA deformity is present. We present an option for correction of the combined deformities with multiplanar angular correction arthrodesis of the first, second, and third tarsometatarsal (TMT) joints.

Triplanar Correction for First Metatarsophalangeal Fusion.

Successful deformity correction utilizing first metatarsophalangeal (MTP) fusion for hallux valgus with concomitant degenerative changes of the first MTP joint is well documented. Currently, there is limited discussion in the literature focusing on triplanar correction of the first MTP arthrodesis. Presented is a novel approach for triplane correction and fusion of the first MTP joint utilizing a biplanar locked plating system.

Biologics in the Treatment of Achilles Tendon.

The treatment of Achilles tendinitis from conservative to minimally invasive to surgery gives patients a wide range of treatment options for this common pathology. The use and role of biologics to augment this treatment is emerging. The use of biologics may enhance the healing potential of the Achilles tendon when conservative treatment fails. There are a handful of biologics being investigated to obtain if improved outcomes can be maximized.

Effect on Foot Width With Triplanar Tarsometatarsal Arthrodesis for Hallux Valgus.

BACKGROUND: Foot width reduction is a desirable cosmetic and functional outcome for patients with hallux valgus. Triplanar first tarsometatarsal (TMT) arthrodesis could achieve this goal by 3-dimensional correction of the deformity. The aim of this study was to evaluate changes in bony and soft tissue width in patients undergoing triplanar first TMT arthrodesis. METHODS: After receiving Institutional Review Board approval, charts were retrospectively reviewed for patients undergoing triplanar first TMT arthrodesis for hallux valgus at 4 institutions between 2016 and 2019. Patients who underwent concomitant first metatarsal head osteotomies (eg, Silver or Chevron) or fifth metatarsal osteotomies were excluded. Preoperative and postoperative anteroposterior weightbearing radiographs were compared to evaluate for changes in bony and soft tissue width. One hundred forty-eight feet from 144 patients (48.1 ± 15.7 years, 92.5% female) met inclusion criteria. RESULTS: Preoperative osseous foot width was 96.2 mm, compared to 85.8 mm postoperatively (P < .001). Preoperative soft tissue width was 106.6 mm, compared to 99.3 mm postoperatively (P < .001). Postoperatively, patients had an average 10.4 ± 4.0 mm reduction (10.8% reduction) in osseous width and average 7.3 ± 4.0 mm reduction (6.8% reduction) in soft tissue width. CONCLUSIONS: Triplanar first TMT arthrodesis reduced both osseous and soft tissue foot width, providing a desirable cosmetic and functional outcome for patients with hallux valgus. Future studies are needed to determine if patient satisfaction and outcome measures correlate with reductions in foot width. Level of evidence: Level III, retrospective comparative study.

Midsubstance Tendinopathy, Surgical Management.

Noninsertional Achilles tendinopathy often responds to nonoperative treatment. When nonoperative treatment fails, the clinician must distinguish between paratendinopathy and noninsertional tendinopathy. In paratendinopathy, myofibroblasts synthesize collagen, causing adhesions, and the paratenon may be released or excised. If a core area of tendinopathy is identified on MRI, the area is excised longitudinally and repaired with a side-to-side suture. If greater than 50% of the tendon diameter is excised, the authors recommend a short flexor hallucis longus tendon transfer with an interference screw. A turndown flap of the gastrocnemius aponeurosis is also described with good results.

Repair of Chronic Achilles Ruptures Has a High Incidence of Venous Thromboembolism.

BACKGROUND: Despite the low incidence of deep vein thrombosis (DVT) in foot and ankle surgery, some authors report a high incidence of symptomatic DVT following Achilles tendon rupture. The purpose of this study was to identify DVT risk factors inherent to Achilles tendon repair to determine which patients may benefit from prophylaxis. METHODS: One hundred and thirteen patient charts were reviewed following elective and nonelective Achilles tendon repair. For elective repair of insertional or noninsertional Achilles tendinopathy, parameters examined included lateral versus prone positioning and the presence versus absence of a flexor hallucis longus transfer. For nonelective repair, acute Achilles tendon ruptures were compared to chronic Achilles tendon ruptures. RESULTS: Of 113 Achilles tendon repairs, 3 venous thromboembolism (VTE) events (2.65%) occurred including 2 pulmonary emboli (1.77%). Seventeen of these repairs were chronic Achilles tendon ruptures, and all 3 VTE events (17.6%) occurred within this subgroup. Elevated body mass index was associated with VTE in patients with chronic Achilles ruptures although this did not reach significance ( P = .064). No VTE events were reported after repair of 28 acute tendon ruptures or after 68 elective repairs of tendinopathy. Two patients with misdiagnosed partial Achilles tendon tears were excluded because they experienced a VTE event 3 weeks and 5 weeks after injury, prior to surgery. CONCLUSION: In our retrospective review, chronic Achilles ruptures had a statistically significant higher incidence of VTE compared with acute Achilles ruptures ( P = .048) or elective repair ( P = .0069). Pharmaceutical anticoagulation may be considered for repair of chronic ruptures. Repair of acute ruptures and elective repair may not warrant routine prophylaxis due to a lower incidence of VTE. LEVELS OF EVIDENCE: Prognostic, Level III: Case Control Study.

Osteotomies for the Management of Charcot Neuroarthropathy of the Foot and Ankle.

Patients with diabetic neuropathy that develop unstable Charcot neuroarthropathy not only have an autoimmune disease that prolongs the healing process, they also often have an inability to maintain a non-weight bearing status. Charcot neuroarthopathy is often devastating to the structure and stability of the foot and ankle. This disease may require permanent bracing, reconstructive surgical stabilization, and in some cases lower leg amputation. Successful management of Charcot neuroarthopathy requires diligence and surveillance by physician and patient alike.

Digital arthrodesis with a one-piece memory nitinol intramedullary fixation device: a retrospective review.

UNLABELLED: A 1-piece memory Nitinol intramedullary fixation device (Smart Toe; Stryker Corporation, Kalamazoo, MI) was used for proximal interphalangeal joint arthrodesis for correction of painful hammertoes in digits 2, 3, and 4. Sixty-five implants were placed in 35 patients. The mean age of our patients was 62.2 years (range = 27-82; standard deviation = 12.5). Mean follow-up time was 27 months (range = 12-40 months; standard deviation = 7). Overall, a 93.8% fusion rate was noted. Complications were noted in 4 patients (6.1%): 1 asymptomatic nonunion (1.5%), 2 hardware failures (3%), and 1 implant displacement (1.5%). To date, no patients required revisional surgery or hardware removal. LEVEL OF EVIDENCE: V.

Exposure of the medial talar dome: bi-plane chevron medial malleolus osteotomy.

Open surgical exposure of the medial aspect of the talus is primarily indicated for osteochondral lesions of the talus and talar body fractures. Secondary to the difficulty of access, a variety of techniques have been described. The surgical techniques described in the literature include transmalleolar access windows, medial and anterior tibial osteotomies, and resection osteotomies (plafondoplasty). The purpose of this article is to describe the surgical technique for the bi-planar chevron osteotomy of the medial malleolus. This osteotomy can provide full exposure to the entire medial aspect of the talus. The orientation of the osteotomy allows for perpendicular placement of instrumentation on the medial half of the talus and is particularly useful for cartilage transplant procedures. The technique is reproducible and has a low complication rate when performed correctly.

Correction of rigid equinovarus deformity using a multiplanar external fixator.

BACKGROUND: The rigid equinovarus foot deformity is a challenging condition treated by the orthopaedic foot and ankle surgeon. Rapid surgical correction of the deformity may lead to skin and neurologic complications. Gradual correction of the deformity with a multiplanar external fixator may decrease these complications. The purpose of this study was to present the results of a group of patients with rigid equinovarus deformities corrected using a multiplanar external fixator. MATERIALS AND METHODS: We retrospectively reviewed the results of correction of a rigid equinovarus deformity using multiplanar external fixation in a small group of patients. All patients underwent open Achilles lengthening, posterior capsule release, tibialis posterior tendon lengthening, flexor digitorum longus and flexor hallux longus lengthening, followed by application of a multiplanar external fixator with gradual correction of the deformity over a period of several weeks. Preoperative and postoperative deformity and AOFAS ankle-hindfoot scores were assessed. RESULTS: A total of eight rigid equinovarus deformities in six patients were treated with a multiplanar external fixator. The average patient age at the time of surgery was 37.2 (range, 17 to 59 ± 15.0) years. Causes of the deformity included trauma in three patients, traumatic brain injury in two patients, and long-standing rheumatoid arthritis in one patient. The average preoperative AOFAS ankle-hindfoot score was 28.3 (range, 12 to 38 ± 7.7). The average postoperative AOFAS ankle-hindfoot score was 68.1 (range 38 to 86 ± 15.5) at an average followup of 71.9 (30 to 120 ± 36.2) weeks. All deformities were gradually corrected to a plantigrade foot using a multiplanar external fixator over an average time of 5 (range, 4 to 6 ± 0.8) weeks. After correction of the deformity, the external fixator was left in place for a time period equal to or twice the length of time it took to achieve correction. The average duration of external fixation was 10.8 (range, 8 to 16 ± 2.8) weeks. Seven of eight deformities maintained correction at final followup. There was one case of recurrence. CONCLUSION: Correction of a rigid equinovarus deformity using a multiplanar external fixator was a viable treatment option. It allowed for correction of the deformity in a controlled manner, helping to reduce the risk of neurovascular complications that may result from single stage surgical correction. The risk of wound complications still exists with the correction of such a complex deformity.

Modern techniques in hallux rigidus surgery.

This article is a review of the history, etiology, and clinical and radiographic presentations of hallux rigidus. The focus is on current treatment options being offered for the treatment of hallux rigidus.

Salvage of severe ankle varus deformity with soft tissue and bone rebalancing.

The etiology of ankle varus is multifactorial. Treatment recommendations after failed conservative care include hindfoot and ankle fusions or total ankle arthroplasty (TAA) with ligament rebalancing. The purpose of this study was to evaluate chronic varus ankle deformities through corrective calcaneal osteotomies and lateral soft tissue reconstruction. All skeletally mature patients with at least 5 degrees of ankle varus were included in the study. Pre and postoperative radiographs were retrospectively reviewed measuring talar tilt. All patients had a lateral closing wedge (Dwyer) calcaneal osteotomy, joint debridement, and lateral ankle ligament reconstruction. Eight feet were included in the study. The average follow-up time was 20.6 months. Six patients (six feet) were asymptomatic and did not have any additional surgery at their most recent follow-up. Two patients failed treatment, requiring surgical intervention for persistent pain and/or deformity. The average postoperative ankle varus correction overall was 4.9 degrees. We found ankle varus on average of less than 10 degrees can be reliably corrected with a combination of lateral ligament reconstruction and calcaneal osteotomy. Approximately 50% of the deformity was corrected when comparing pre and postoperative talar tilt values. In patients with varus deformity greater than 10 degrees preoperatively, persistent varus may occur.

Single-screw fixation for subtalar joint fusion does not increase nonunion rate.

A philosophical shift toward more joint-sparing procedures has led to increased use of isolated subtalar joint (STJ) versus triple arthrodesis. Union rates for STJ fusion range from 47% to 100%, leading to controversy regarding the optimal type, orientation, and amount of internal fixation. The purpose of this study was to determine if single-screw fixation is a predisposing factor to nonunion. Single-screw fixation is parallel to the STJ axis and may result in motion. It is hypothesized that higher nonunion rates will be observed in single-screw versus 2-screw fusions. Isolated STJ arthrodeses performed in 113 patients were retrospectively reviewed. Single screws were used in 89 (78.8%) fusions; 2 screws were used in 24 (21.2%) fusions. The mean follow-up was 11 months (range, 9-17 months). Nonunion occurred in 13 (14.6%) single-screw and 6 (25.0%) 2-screw fusions. Twenty (22.5%) single-screw and 3 (12.5%) 2-screw fusions required hardware removal. Revision surgery was performed in 6 (6.7%) single-screw and 3 (12.5%) 2-screw fusions. No significant differences in demographics were calculated between single and 2-screw fusions. Furthermore, no significant differences were observed in nonunion rate, postoperative complication incidence, or subsequent surgeries. The results from this study do not support the contention that single-screw fixation predisposes STJ fusions to nonunion. Comparable nonunion and complication incidences were observed between single and 2-screw fusions. These data suggest that the motion occurring from single-screw fixation may not be significant enough to directly affect the rate of union.

Negative-pressure wound therapy applied to high-risk surgical incisions.

Negative-pressure wound therapy (NPWT) is commonly used for chronic wounds, open fractures with soft tissue defects, and coverage over split-thickness skin grafts. NPWT uniformly draws wounds closed by helping to remove interstitial fluid, which contains inflammatory and potentially infectious exudate that could impair healing. Recently in our practice, we have used NPWT in cases involving tenuous incisions, such as those used to access target structures during total ankle replacement or open repair of joint depression calcaneal fractures, in an effort to prevent hematoma or wound dehiscence. Although it is generally understood that NPWT can be efficacious and cost-effective for management of a wide range of lower extremity wounds, we also believe it to be beneficial in the management of low-energy trauma and elective hindfoot and ankle reconstructions, and feel that it has led to decreased pain, swelling, and time to healing in our patients. Based on our experience with ankle arthroplasty and the surgical management of hindfoot and ankle trauma, we believe that the use of NWPT in the immediate postoperative period is both safe and efficacious.

Early clinical experience with a fresh talar transplant inlay allograft for the treatment of osteochondral lesions of the talus.

BACKGROUND: Management of osteochondral defects of the talus remains a challenge, and many lesions do not respond to traditional treatments. The use of fresh allografts is a promising alternative. METHODS: A freehand inlay surgical technique for reconstructing osteochondral defects of the talus with fresh osteochondral allografts fixated with bioresorbable chondral darts is described. A retrospective review of a consecutive series of 15 patients (eight males and seven females; mean age, 42.2 years) with stage IV osteochondral defects who underwent this procedure is presented. Seven patients reported a history of trauma. The mean lesion diameter was 1.7 cm. RESULTS: Mean follow-up was 1.6 years. The Foot and Ankle Outcome Score subscale mean scores obtained at the most recent follow-up were as follows: 66.0 (pain), 64.8 (other symptoms), 71.2 (activities of daily living), 50.7 (sport and recreation function), and 42.1 (quality of life). Nine lesions had no evidence of lucency, and six demonstrated mild lucency, indicating that no allograft had been absorbed. Most patients exhibited no step-off deformity or arthrosis. No graft-related complications occurred. No subsequent surgical procedures were required. CONCLUSIONS: Early results suggest that this technique is a viable option for treating large osteochondral defects of the talus, as evidenced by the favorable patient assessment and radiographic outcomes and the lack of postoperative complications and subsequent procedures. Unlike previous allograft techniques, hardware complications did not occur. Based on these results, this technique will continue to be used.