Twelve-Year Progression of Osteochondral Lesions of the Talus Observed Using Magnetic Resonance Imaging.

Osteochondral lesions of the talus are common injuries that are most often the result of trauma. The natural progression of osteochondral lesions is not well understood. It is still unclear which lesions eventually lead to joint degeneration and osteoarthritic changes and if the treatment method affects the progression. The existing literature surrounding this topic is sparse, with inconsistent findings. The presented images are taken from a 72-year-old man with bilateral osteochondral lesions of the talus. To our knowledge, this is the first published series of images illustrating the natural progression of a patient with bilateral osteochondral lesions of the talus over a 12-year time period.

Time and State Legislation Have Decreased Opioid Prescribing in Elective Foot and Ankle Surgery in the United States.

BACKGROUND: Legislation in the United States has been enacted to reduce opioid overuse and abuse in the setting of the opioid epidemic, and a notable target has been opioid overprescription. However, the impact of this legislation on elective foot and ankle surgery is largely unknown. The purpose of this study was to evaluate the impact of opioid-limiting legislation on opioid prescribing in elective foot and ankle surgery. METHODS: The 90-day perioperative opioid prescription filling in oxycodone 5-mg equivalents was identified in all patients 18 years of age and older undergoing nontrauma, nonarthroplasty foot and ankle surgery from 2010 to 2019 using a commercial database. States with and without legislation were identified, and opioid prescription filling before and after the legislation were tabulated. Unadjusted and adjusted analyses were performed to evaluate the impact of time and state legislation on perioperative opioid prescribing in this patient population. RESULTS: Initial and cumulative opioid prescribing decreased significantly from 2010 to 2019 (39 vs 35.7 initial and 98.1 vs 55.7 cumulative). States with legislation had larger and more significant reductions in initial and cumulative opioid prescribing compared with states without legislation over similar time frames (41.6 to 35.1 with legislation vs 40.6 to 39.1 without legislation initial prescription filling volume and 87.7 to 62.8 vs 88.6 to 74.1 cumulative prescription filling volume). CONCLUSION: State legislation and time have been associated with large, clinically relevant reductions in 90-day perioperative cumulative opioid prescription filling, although reductions in initial opioid prescription filing have remained low. These results encourage states without legislation to enact restraints to reduce the opioid epidemic. LEVELS OF EVIDENCE: Level III: Retrospective, prognostic cohort study.

The Impact of Time and State Opioid Legislation on Opioid Prescription Filling in Total Ankle Arthroplasty.

Total ankle arthroplasty (TAA) is an increasingly utilized treatment for ankle arthritis, and opioids are commonly used as part of perioperative pain control. However, many states have enacted opioid-limiting legislation to reduce perioperative opioid prescribing. The aim of this study was to evaluate the impact of time and state legislation on perioperative opioid prescribing in TAA. This study is a retrospective, observational review of 90-day perioperative opioid prescribing in 1,829 patients undergoing TAA throughout the United States using a large insurance database. Initial and cumulative volumes and rates of opioid prescription filling were recorded along with baseline patient and operative characteristics. Dates of state legislation enactment were also recorded. Student t-tests, analysis of variance, and multivariable linear and logistic regression were utilized to analyze the impact of time and state legislation on opioid prescription filling. In the 90-day perioperative time period, initial and cumulative opioid prescription filling in oxycodone 5-mg equivalents has decreased significantly from 2010 (63.8 initial and 163.3 cumulative) to 2019 (41.1 initial and 67.2 cumulative). States with opioid-limiting legislation saw larger and more significant reductions in initial and cumulative opioid prescription filling preact to postact (63.3-50.6 with legislation vs 61.4-51.9 without legislation initial and 146.4-93.3 with legislation vs 125.1-108.6 without legislation cumulative). This study demonstrates that foot and ankle surgeons in states with opioid-limiting legislation have responded by significantly reducing 90-day perioperative opioid prescribing in TAA. These results encourage states without legislation to enact opioid-specific laws to reduce opioid prescribing.

Histologic grading correlates with inflammatory biomarkers in tibialis posterior tendon dysfunction.

BACKGROUND: It has been theorized that tibialis posterior tendon dysfunction (TPTD) is a degenerative process unrelated to inflammation. The purpose of this study was to determine if inflammatory cytokines, matrix metalloproteases (MMPs), and glutamate were elevated in diseased tibialis posterior tendons (TPTs). METHODS: Matched diseased TPT, TPT insertion, and flexor digitorum longus (FDL) samples were collected from 21 patients. The samples were individually incubated in media, which was analyzed for inflammatory cytokines, MMPs, and glutamate. Histology and statistical analyses were performed. RESULTS: Diseased TPT and TPT insertion were significantly elevated compared to transferred FDL in eight inflammatory markers (p < 0.005). Only the diseased TPT was significantly elevated compared to the transferred FDL tendons for glutamate (p < 0.01). Histologic grading correlated with inflammatory cytokine levels. CONCLUSION: Diseased TPT and TPT insertion demonstrated significantly elevated levels of inflammatory markers compared to the transferred tendons used as controls, suggesting a role for inflammation in the disease process. The amount of inflammation correlated with increased tendon degradation. LEVEL OF EVIDENCE: Level III.

Avascular Necrosis of the Talus After Subchondroplasty.

BACKGROUND: Subchondroplasty (SCP) is a relatively new procedure, developed in 2007 for the treatment of bone marrow lesions (BMLs), that has shown promising results in the knee through several different case series. The foot and ankle literature, however, is sparse, with only a few documented case reports or case series. At our institution, we have identified several patients with complications after this specific procedure. As a result, we report our case series of patients who developed talar avascular necrosis (AVN) after undergoing SCP. METHODS: A retrospective review was performed of patients who underwent SCP for a talar BML at our facility or who were referred to our facility after undergoing SCP at an outside institution. Patients were included if they developed radiographic evidence of talar AVN after the procedure. Patient demographics, comorbidities, concomitant intraoperative procedures, complications, and subsequent interventions were reviewed. RESULTS: Seven patients were identified as having radiographic evidence of talar AVN after SCP. Average time interval was 23 months postoperative from index procedure to radiographic confirmation of AVN. Two of the index procedures were performed at our institution, whereas 5 of the index procedures were performed at outside institutions and referred for further management. Three patients had documented risk factors for AVN before the SCP procedure. All 7 patients were symptomatic from the AVN. CONCLUSION: We identified 7 patients who went on to develop talar AVN after having undergone SCP. LEVEL OF EVIDENCE: Level IV, case series.

From Patient to Procedure: The Process of Creating a Custom 3D-Printed Medical Device for Foot and Ankle Pathology.

Three-dimensional (3D) printing technology has advanced greatly over the past decade and is being used extensively throughout the field of medicine. Several orthopaedic surgery specialties have demonstrated that 3D printing technology can improve patient care and physician education. Foot and ankle pathology can be complex as the 3D anatomy can be challenging to appreciate. Deformity can occur in several planes simultaneously and bone defects either from previous surgery or trauma can further complicate surgical correction. Three-dimensional printing technology provides an avenue to tackle the challenges associated with complex foot and ankle pathology. A basic understanding of how these implants are designed and made is important for surgeons as this technology is becoming more widespread and the clinical applications continue to grow within foot and ankle surgery.Levels of Evidence: Level V.

Clinical applications of custom 3D printed implants in complex lower extremity reconstruction.

BACKGROUND: Three dimensional printing has greatly advanced over the past decade and has made an impact in several industries. Within the field of orthopaedic surgery, this technology has vastly improved education and advanced patient care by providing innovating tools to complex clinical problems. Anatomic models are frequently used for physician education and preoperative planning, and custom instrumentation can assist in complex surgical cases. Foot and ankle reconstruction is often complicated by multiplanar deformity and bone loss. 3D printing technology offers solutions to these complex cases with customized implants that conform to anatomy and patient specific instrumentation that enables precise deformity correction. CASE PRESENTATION: The authors present four cases of complex lower extremity reconstruction involving segmental bone loss and deformity - failed total ankle arthroplasty, talus avascular necrosis, ballistic trauma, and nonunion of a tibial osteotomy. Traditional operative management is challenging in these cases and there are high complication rates. Each case presents a unique clinical scenario for which 3D printing technology allows for innovative solutions. CONCLUSIONS: 3D printing is becoming more widespread within orthopaedic surgery. This technology provides surgeons with tools to better tackle some of the more challenging clinical cases especially within the field of foot and ankle surgery.

Hallux Valgus.

Hallux valgus is a common condition that results from a complex positional deformity of the first ray. The bunion or medial prominence that results from the lateral deviation and pronation of the hallux is only one component of the 3-dimensional deformity. Hallux valgus can lead to considerable pain and altered joint mechanics. The precise biomechanical etiology remains under debate. Predisposing factors include female sex, age, constricting footwear, and family history. Metatarsus adductus, equinus contracture, hammertoe deformity, and pes planus often coexist with hallux valgus. Nonoperative treatment involves patient education, shoe modifications, toe pads and positioning devices, and activity modifications. Surgery is considered in patients who fail nonoperative treatment with the goal of pain relief, correction of the deformity, improved first ray stability, and improved quality of life. More than 100 different procedures have been described to treat hallux valgus; they include combinations of soft tissue balancing, metatarsal osteotomies, and fusion of either the metatarsophalangeal (MTP) or tarsometatarsal (TMT) joint. The choice of procedures depends on the severity and location of the deformity as well as surgeon preference. Recent advances in operative techniques include minimally invasive surgery and correction of rotational deformity.

Osseointegrated Transcutaneous Device for Amputees: A Pilot Large Animal Model.

Traditional above-the-knee amputation prosthetics utilize a stump-socket interface that is well-known for skin/socket problems, sitting difficulty, disuse osteopenia, and increased work of ambulation. As a result, we evaluated a novel osseointegrated transcutaneous implant in a large animal. The implant was designed to promote osseointegration at the bone-implant interface and minimize complications. As proof of concept, four Dorset sheep underwent a two-stage surgery for forelimb placement of an osseointegrated transcutaneous implant utilizing Compress® technology (Biomet, Inc., Warsaw, IN). Two sheep received a long anchor plug (90 mm long x 9 mm in diameter) and two received a short anchor plug (46 mm long x 9 mm in diameter). Sixteen weeks after the initial surgery, the operative limbs, along with the attached implant, underwent radiographic and histological analysis for osseointegration. Periprosthetic fractures occurred in the two animals that received the longer internal prosthesis; one healed with splinting and the other animal underwent a second surgical procedure to advance the amputation site more proximal. No fractures occurred in the shorter internal prosthesis group. There was no histological evidence of infection and none of the transcutaneous adapters failed. Bone-implant osseointegration was demonstrated in two of three limbs that underwent histological analysis. This unique implant demonstrated osseointegration without transcutaneous adapter failure, all while displaying minimal infection risk from the outside environment. Although it involved short-term follow-up in a limited number of animals, this pilot study provides a platform for further investigation into the valid concept of using Compress® technology as an endo-exo device.

Posterior Tibialis Tendon Rupture in a Closed Bimalleolar-Equivalent Ankle Fracture: Case Report.

Ankle fractures with an associated posterior tibialis tendon (PTT) rupture are rare injuries and have only been described in a number of case reports. These prior reports include patients that had an open fracture and/or an associated medial malleolar fracture component. In this unique case report, we present a patient that sustained a closed bimalleolar-equivalent ankle fracture/dislocation without medial malleolar involvement which was irreducible due to a PTT rupture and subsequent distal segment interposition in the tibiotalar joint. Identification of acute PTT rupture with associated ankle fracture is important because early repair is associated with significantly better functional outcomes compared with late repair. These injury patterns may easily be missed due to the limitations with physical examination and standard imaging often encountered during initial evaluation of routine ankle fractures. Therefore, physicians should maintain a high level of suspicion in the appropriate clinical setting in order to provide appropriate diagnosis and timely surgical intervention. LEVELS OF EVIDENCE: Descriptive, Level V: Single case report.

Acute Rupture Open Repair Techniques.

Achilles tendon injuries can be serious injuries requiring either operative or nonoperative management. For appropriate surgical candidates, operative intervention may provide lower rerupture rates and adequate end-to-end tendon healing. Our preference is an open Achilles tendon repair, specifically a limited open technique using the PARS device (Arthrex, Naples, FL). Postoperatively, we use functional rehabilitation and early range of motion. Although the current literature remains controversial regarding operative versus nonoperative management, the authors have obtained satisfactory results in appropriately chosen surgical candidates.

Smartphone assessment of knee flexion compared to radiographic standards.

BACKGROUND: Measuring knee range of motion (ROM) is an important assessment for the outcomes of total knee arthroplasty. Recent technological advances have led to the development and use of accelerometer-based smartphone applications to measure knee ROM. The purpose of this study was to develop, standardize, and validate methods of utilizing smartphone accelerometer technology compared to radiographic standards, visual estimation, and goniometric evaluation. METHODS: Participants used visual estimation, a long-arm goniometer, and a smartphone accelerometer to determine range of motion of a cadaveric lower extremity; these results were compared to radiographs taken at the same angles. RESULTS: The optimal smartphone position was determined to be on top of the leg at the distal femur and proximal tibia location. Between methods, it was found that the smartphone and goniometer were comparably reliable in measuring knee flexion (ICC=0.94; 95% CI: 0.91-0.96). Visual estimation was found to be the least reliable method of measurement. CONCLUSIONS: The results suggested that the smartphone accelerometer was non-inferior when compared to the other measurement techniques, demonstrated similar deviations from radiographic standards, and did not appear to be influenced by the person performing the measurements or the girth of the extremity.

Operative Cost Comparison: Plating Versus Intramedullary Fixation for Clavicle Fractures.

Although clavicle fractures often heal well with nonoperative management, current literature has shown improved outcomes with operative intervention for specific fracture patterns in specific patient types. The 2 most common methods of midshaft clavicle fracture fixation are intramedullary and plate devices. Through retrospective analysis, this study performed a direct cost comparison of these 2 types of fixation at a single institution over a 5-year period. Outcome measures included operative costs for initial surgery and any hardware removal surgeries. This study reviewed 154 patients (157 fractures), and of these, 99 had intramedullary fixation and 58 had plate fixation. A total of 80% (79 of 99) of intramedullary devices and 3% (2 of 58) of plates were removed. Average cost for initial intramedullary placement was $2955 (US dollars) less than that for initial plate placement (P<.001); average cost for removal was $1874 less than that for plate removal surgery (P=.2). Average total cost for all intramedullary surgeries was $1392 less than the average cost for all plating surgeries (P<.001). Average cost for all intramedullary surgeries requiring plate placement and removal was $653 less than the average cost for all plating surgeries that involved only placement (P=.04). Intramedullary fixation of clavicle fractures resulted in a statistically significant cost reduction compared with plate fixation, despite the incidence of more frequent removal surgeries. [Orthopedics.2016; 39(5):e877-e882.].

Contamination Relative to the Activation Timing of Filtered-Exhaust Helmets.

BACKGROUND: Filtered-exhaust helmet systems are commonplace during total joint arthroplasty, but their ability to limit intraoperative contamination has been questioned. We hypothesized that activation of the airflow system after complete gowning would lead to decreased contamination of the surgical environment. METHODS: Using a fluorescent particle model, the maximal particle spread from a filtered-exhaust helmet and contamination of the surgical environment based on timing of airflow activation through simulated surgical gowning procedures were evaluated. RESULTS: Helmet airflow analysis revealed particle spread greater than 5 feet in all trials. Activation before gowning resulted in a significantly greater contamination in the control group compared with the experimental group (P = .014). CONCLUSIONS: We recommend complete surgical gowning before activation of the airflow system.

Economic impact of syndesmosis hardware removal.

Ankle syndesmosis injuries are commonly seen with 5-10% of sprains and 10% of ankle fractures involving injury to the ankle syndesmosis. Anatomic reduction has been shown to be the most important predictor of clinical outcomes. Optimal surgical management has been a subject of debate in the literature. The method of fixation, number of screws, screw size, and number of cortices are all controversial. Postoperative hardware removal has also been widely debated in the literature. Some surgeons advocate for elective hardware removal prior to resuming full weightbearing. Returning to the operating room for elective hardware removal results in increased cost to the patient, potential for infection or complication(s), and missed work days for the patient. Suture button devices and bioabsorbable screw fixation present other options, but cortical screw fixation remains the gold standard. This retrospective review was designed to evaluate the economic impact of a second operative procedure for elective removal of 3.5mm cortical syndesmosis screws. Two hundred and two patients with ICD-9 code for "open treatment of distal tibiofibular joint (syndesmosis) disruption" were identified. The medical records were reviewed for those who underwent elective syndesmosis hardware removal. The primary outcome measurements included total hospital billing charges and total hospital billing collection. Secondary outcome measurements included average individual patient operative costs and average operating room time. Fifty-six patients were included in the study. Our institution billed a total of $188,271 (USD) and collected $106,284 (55%). The average individual patient operating room cost was $3579. The average operating room time was 67.9 min. To the best of our knowledge, no study has previously provided cost associated with syndesmosis hardware removal. Our study shows elective syndesmosis hardware removal places substantial economic burden on both the patient and the healthcare system.

Total ankle arthroplasty with severe preoperative varus deformity.

Advancements in total ankle arthroplasty (TAA) over the past several decades have led to improved patient outcomes and implant survivorship. Despite these innovations, many implant manufacturers still consider a preoperative coronal plane deformity greater than 10° a relative contraindication to TAA. Without proper intraoperative alignment, these implants may experience abnormal wear and hardware failure. Correcting these deformities, often through the use of soft tissue procedures and/or osteotomies, not only increases the difficulty of a case, but also the intraoperative time and radiation exposure. The authors report a case in which a 54-year-old man with a severe right ankle varus deformity of 29° underwent successful TAA using the INBONE II Prophecy total ankle system (Wright Medical Technology, Inc, Memphis, Tennessee) and additional soft tissue reconstruction. Intraoperatively, the patient's coronal deformity was corrected to 1.8°. At 8 months postoperatively, the patient ambulated without restriction and had substantial improvement in validated patient outcome scores, specifically the Academy of Orthopaedic Surgeons Foot and Ankle Module and the Short Form Health Survey-12 This unique report documents the first time that this particular implant, with an exclusive preoperative computed tomography-derived patient-specific guide, has been used effectively for a severe preoperative varus deformity greater than 20° without the need for an osteotomy. Future studies should be directed toward the prospective evaluation of different total ankle implant systems and their outcomes with severe coronal plane deformity, specifically computed tomography-derived patient-specific guided implants.

Topical Review: Use of Fetal Tissue in Foot and Ankle Surgery.

UNLABELLED: Fetal tissues are well known for their therapeutic potential. They contain numerous growth factors, cytokines, and matrix components that promote regeneration of tissues while downregulating inflammation and scar formation. As a result, use of these treatments has expanded over the previous 20 years throughout various surgical specialties, including orthopaedics. With improved methods of sterilization, processing, and storage, surgeons need to be informed about the potential benefits of fetal tissue in foot and ankle surgery. The aim of this review is to provide a brief historical background, basic anatomy and physiology, and a current review of the literature in regard to chronic wounds, diabetic foot ulcerations, plantar fasciitis, tendon repair, adhesion prevention, nerve repair, and bone healing. LEVELS OF EVIDENCE: Level V: Expert Opinion.

Cryopreserved human amniotic membrane injection for plantar fasciitis: a randomized, controlled, double-blind pilot study.

BACKGROUND: Treatment options for plantar fasciitis have resulted in varied patient outcomes. The aim of this study was to compare a novel treatment, cryopreserved human amniotic membrane (c-hAM), to a traditional treatment, corticosteroid. Our hypothesis was that c-hAM would be safe and comparable to corticosteroids for plantar fasciitis in regard to patient outcomes. METHODS: A randomized, controlled, double-blind, single-center pilot study was completed. Patients were randomized into one of 2 treatment groups: c-hAM or corticosteroid. Patients received an injection at their initial baseline visit with an option for a second injection at their first 6-week follow-up. Total follow-up was obtained for 12 weeks after the most recent injection. The primary outcome measurement was the Foot Health Status Questionnaire (FHSQ). The secondary outcome measurements were the Visual Analog Scale (VAS) and verbally reported percentage improvement. Data were analyzed between groups for the 2 different cohorts (1 injection versus 2 injections). Twenty-three patients had complete follow-up. Fourteen were randomized to receive corticosteroid and 9 were randomized to receive c-hAM. RESULTS: Three patients in each group received second injections. With the numbers available, the majority of outcome measurements showed no statistical difference between groups. The corticosteroid did, however, have greater FHSQ shoe fit improvement (P = .0244) at 6 weeks, FHSQ general health improvement (P = .0132) at 6 weeks, and verbally reported improvement (P = .041) at 12 weeks in the one-injection cohort. Cryopreserved hAM had greater FHSQ foot pain improvement (P = .0113) at 18 weeks in the 2-injection cohort. CONCLUSION: Cryopreserved hAM injection may be safe and comparable to corticosteroid injection for treatment of plantar fasciitis. This is a pilot study and requires further investigation. LEVEL OF EVIDENCE: Level I, prospective randomized trial.

Effect of Dorsal Plate Positioning on Dorsiflexion Angle in Arthrodesis of the First Metatarsophalangeal Joint: A Cadaveric Study.

BACKGROUND: The relationship between dorsal plate positioning and final dorsiflexion angle after first metatarsophalangeal (MTP) joint fusion has not been well established. The main purpose of this study was to investigate whether changes in dorsal plate positioning along the longitudinal axis affect fusion dorsiflexion angle, as excessive dorsiflexion angles can lead to poor clinical results. METHODS: Ten cadaver foot specimens were randomly assigned to 2 groups for first MTP joint fusion: 1 group used a straight plate, and the other group used a 10-degree precontoured plate. After routine preparation, the plates were placed in an "ideal" position based on clinical and radiological examination. The plates were then moved proximally 3 mm and 6 mm from the initial site, with repeat imaging completed at each position. The radiological dorsiflexion angle was determined for each position, and the results were assessed. RESULTS: Placement of both straight and precontoured plates at positions more proximal from the initial position led to significant increases in dorsiflexion angles (P = .04), although the percentage change was larger in the precontoured plate group (P = .01). While placement of the plate 3 mm proximal from the perceived "ideal" position did increase the dorsiflexion angle, the percentage of specimens with dorsiflexion angles in the suggested optimal range changed minimally. Positioning at 6 mm from the starting point, however, led to significantly increased dorsiflexion angles for both plates (P = .004). CONCLUSION: Positioning the dorsal plate at more proximal locations leads to increasing dorsiflexion angles. Precontoured plates are more likely to lead to excessive dorsiflexion compared with straight plates regardless of plate position. CLINICAL RELEVANCE: Fusion at excessive dorsiflexion angles can be minimized with appropriate selection and proper positioning of the dorsal fusion plate along the longitudinal axis.