Secondary Surgery Following Lapidus Bunionectomy.

While the Lapidus bunionectomy is a common procedure utilized to address hallux valgus, the incidence of secondary surgery is not well established. Our primary goal was to determine the incidence of revision surgery and hardware removal following the Lapidus bunionectomy in addition to the risk factors associated with each. A retrospective nested case-control study of adult patients who underwent a Lapidus bunionectomy for symptomatic hallux valgus over a nine-year period was performed. The incidence rates and 95% confidence intervals (CI) of secondary surgery in the three years following the procedure along with the estimated independent associations and odds ratios between baseline demographic, clinical, and radiographic characteristics were calculated. Of the original cohort of 2,540 patients, 127 were identified (5.0%; CI: 4.1%, 5.8%) who underwent revision surgery and 165 (6.5%; CI: 5.5%, 7.5%) who underwent hardware removal following Lapidus bunionectomy. Initially, the hallux valgus angle, intermetatarsal angle, and tibial sesamoid position were risk factors for revision surgery. However, in adjusted analyses for revision surgery, using a screw for third point of fixation emerged as the only independent risk factor (odds ratio [OR]=3.01; CI: 1.59, 5.69). In adjusted analyses for hardware removal, female sex (OR=2.33; CI: 1.08, 5.00) and third point of fixation (OR=2.92; CI: 1.82, 4.69) emerged as independent risk factors. While the overall risks associated with Lapidus bunionectomy are low and the need for revision surgery are low, this study helps to identify specific risk factors for secondary surgery and hardware removal to help in evaluation and discussion with patients. LEVEL OF EVIDENCE: : 4.

Mid-term Incidence of Tarsometatarsal Joint Arthrodesis Following Open Reduction With Internal Fixation (ORIF) of Lisfranc Injuries.

Open reduction with internal fixation (ORIF) of Lisfranc injuries are associated with an increased risk for secondary surgery including hardware removal and salvage arthrodesis. In the current literature, rates of salvage arthrodesis vary due to small sample sizes and a low incidence of Lisfranc injuries. There is little evidence to identify specific surgical and patient-related variables that may result in later arthrodesis. The purpose of this study is to determine the rate of tarsometatarsal joint arthrodesis following Lisfranc ORIF in a relatively large sample size. This retrospective review included patients who underwent ORIF for a Lisfranc injury between January 2007 and December 2012. A total of 146 patients met our criteria. Trans-articular fixation was used in 109 (74.6%) patients, 33 (22.6%) received percutaneous fixation and 4 (2.7%) extraarticular fixation. Five out of 120 (4.2%) patients required a salvage arthrodesis for post-traumatic arthritis that had a follow-up greater than 5 y but up to 10 y. The mean age of patients who underwent arthrodesis after ORIF was 24.5 ± 11.95 (16-48) y compared to 40.9 ± 15.8 (16-85) y. Patients who required an arthrodesis also had earlier hardware removal than patients who did not have an arthrodesis, 71.2 ± 28.3 (38-100) days and 131.4 ±101.2 (37-606) days, respectively. Patients who required salvage arthrodesis tended to be younger and hardware was removed earlier compared to those patients who did not require an arthrodesis. Four of the 5 patients who underwent a secondary arthrodesis had a loss of correction after hardware removal.

Crossed Screw Fixation Versus Dorsal Plating for First Metatarsophalangeal Joint Arthrodesis: A Retrospective Cohort Study.

Multiple fixation techniques for first metatarsophalangeal joint arthrodesis have been described with an average fusion rate of 93.5%. This retrospective cohort study assesses the association between crossed screws (vs dorsal plating) and medical comorbidities and the outcome radiographic union. Bivariate tests of association and multivariable logistic regression were employed to assess differences across fixation type and outcomes. We identified 305 patients who underwent a first metatarsophalangeal joint arthrodesis during the study period. Crossed screw fixation was used in 158 (51.8%) patients while dorsal plating (tubular or anatomic locking plate) was used in 147 (48.2%) patients. Dorsal plating was utilized more often in patients with rheumatoid arthritis (p = .019) and history of smoking (p = .044). At 12 weeks post-operatively there were no significant differences in fusion rates between the two groups (crossed screw group = 95.3% vs dorsal plate group (referent) = 93.5%, Adjusted odds ratio (AOR) 1.39, 95% confidence interval [CI] 0.45-4.26). Not smoking was associated with a greater odds of fusion at 12 weeks (96.2% for nonsmokers vs 75.0% for smokers (referent), AOR 0.07, 95% CI 0.02-0.28). Lower body mass index was associated with a greater odds of fusion at 12 weeks (AOR 0.90, 95% CI 0.82-0.99). Surgeons allowed weightbearing earlier with dorsal plate fixation (2 weeks (interquartile range [IQR] 2.6) versus 5 weeks (IQR 2.6) for crossed screw fixation, p = .001). Patients with multiple medical comorbidities were more likely to require revision surgery than patients having 0-1 comorbidities (p < .05). Crossed screws can provide an inexpensive yet effective option for first metatarsophalangeal joint arthrodesis.

Success and Survivorship Following Charcot Reconstruction: A Review of 151 Cases.

Charcot neuroarthropathy is a debilitating condition that frequently leads to skeletal deformity and pedal ulceration in the insensate foot. Results are often poor and no clear guidelines for surgical management exist. Additionally, amputation rates vary widely making it difficult to accurately inform patients of risks. Few studies have assessed outcomes to identify patients for whom reconstruction is likely to fail. The literature is limited, with small sample sizes and mortality infrequently addressed. We performed a retrospective observational study of patients with Charcot neuroarthropathy to assess overall amputation and mortality rates at 30 days, 1 year, and 3 years postreconstruction and evaluated associated risk factors. Rates of infection, re-ulceration, and return to walking were also assessed. We identified 151 patients over a 5-year period. Demographic and clinical characteristics were collected. Descriptive statistics, Cox proportional hazard model, and logistic regression were used. Overall, 22 (14.6%) patients died, and 23 (15.2%) patients advanced to limb amputation postoperatively. End-stage renal disease, peripheral vascular disease, reconstruction during active phase Charcot process, and reconstruction at the ankle or subtalar joint were all associated with poor outcomes. The risk of mortality was 2.5 times higher in patients with end-stage renal disease, and 3.4 times higher among patients with peripheral vascular disease. Patients with ankle or subtalar joint reconstruction were 70% less likely to return to walking compared to medial column reconstruction. Due to these findings, we suggest that patients with such comorbidities be advised of increased risk for complications including failure to return to walking, amputation, and death.

Minimally Invasive Intermetatarsal Nerve Decompression for Morton's Neuroma: A Review of 27 Cases.

Minimally invasive nerve decompression for operative management of Morton's neuroma has been shown to be an effective alternative to neurectomy; however, little is known about postoperative outcomes. In this retrospective case series, we reviewed 27 procedures in 25 patients who underwent minimally invasive nerve decompression as primary surgical management for Morton's neuroma. Most subjects (22, or 88%) had 12 or more months of health plan enrollment postoperatively; 3 (12%) had 4 to 7 months of enrollment after the procedure. Postoperative patient satisfaction, complications and the need for a follow-up neurectomy were ascertained from medical record review. Additionally, demographic and clinical data were extracted from electronic sources. Patient satisfaction was unknown for 5 (18.5%) of the 27 procedures. Among the 22 (81.5%) procedures for which there were valid patient satisfaction data, patient satisfaction was excellent for 11 (50%); good for 2 (9.1%), and poor for 9 (40.9%). During the follow-up period, 5 (18.5%) patients required an open neurectomy. Among the 6 (22.2%) patients who presented without a Mulder's sign on physical exam preoperatively, 83% reported excellent results. Minimally invasive nerve decompression may not be as effective as previously seen; however, it may be indicated in patients presenting with absence of a Mulder's sign, a physically small or nascent neuroma.

The Correlation of the Trans-Atlantic Inter-Society Consensus Classification to Outcomes of Pedal Amputations.

In an attempt at limb salvage for patients with peripheral arterial disease, revascularization is often performed prior to pedal amputation. The purpose of this study was to evaluate the association between proximal arterial lesions, based on Trans-Atlantic Inter-Society Consensus aortoiliac, femoropopliteal, and infrapopliteal classifications, and healing pedal amputations post endovascular revascularization. Patients with revascularization up to 90 days prior to pedal amputation with a minimum of 12 months postoperative follow-up were included. Each level of proximal disease was subdivided into Trans-Atlantic Inter-Society Consensus classifications A through D, which range in severity from a single short stenosis or occlusion to more complex stenoses and chronic total occlusion. For comparison, we categorized A and/or B lesions into Group 1 and C and/or D lesions into Group 2. The frequency of proximal lesions was recorded as either isolated, bi-level, or multilevel disease. Chi-square and Fisher's exact tests were used to compare categorical variables. Of the 310 patients, there were a total of 68 aortoiliac, 256 femoropopliteal, and 172 infrapopliteal lesions; 140 patients had isolated lesions, 154 had bi-level disease, and 16 had multilevel disease. Although not statistically significant, patients in Group 1 (A and/or B lesions) had higher proportion of failed amputation compared to Group 2 (C and/or D lesions) in either aortoiliac (84.4% vs 15.6%, p = .17), femoropopliteal (61.2% vs 38.8%, p = .72), or infrapopliteal (57.3% vs 42.7%, p = .44). Bi-level disease showed a higher proportion of failure (50.6%) compared to isolated lesions (43.8%) and multilevel disease (5.6%), (p = .86). To our knowledge, this is the first study to evaluate the association between Trans-Atlantic Inter-Society Consensus arterial lesions and incisional healing of pedal amputations. Despite our belief, there was no correlation between patients with simple, isolated lesions compared to either complex arterial lesions or multilevel disease in healing pedal amputations.

The Effects of Endovascular Timing and In-line Flow on the Success of Pedal Amputations.

There has been a growing trend toward endovascular intervention to improve peripheral flow in patients with peripheral arterial disease. To date, there is no clear consensus regarding timing of lower-extremity amputations after revascularization. The purpose of this study was to evaluate the effects of timing between endovascular intervention and minor lower-extremity amputations and its influence on wound healing and limb loss within 1 year. A secondary purpose was to evaluate the impact of restoring in-line flow on healing rates. A total of 310 patients who underwent endovascular intervention and a minor lower-extremity amputation within 90 days were included in the study. Healing rates were defined as optimal, delayed, or failure. There was a statistically significant difference between patients with optimal healing to delayed healing and amputation ≥30 days after endovascular intervention (p = .037). We found no difference in healing rates in regard to amputation timing when examining patients who ultimately healed versus patients who failed to heal (p = .6717). Absence of in-line flow (p = .0177), male sex (p = .0090) and diabetes mellitus (p = .0076) were statistically significant factors for failing to heal. Presence of infection (p ≤ .0001) and wound dehiscence (p ≤ .001) were also associated with a failure to heal. End-stage renal disease trended toward significance for failing to heal (p = .065). Amputation-free survival at 1 year after endovascular intervention and pedal amputation was 76.8% (n = 238). Our findings suggest that in the absence of infection, performing minor lower-extremity amputations 15 to 60 days after endovascular intervention may allow for improved healing. Absence of in-line flow, male sex, diabetes mellitus, postoperative infection, and wound dehiscence are significant factors for failure.

The Epidemiology of Metatarsal Fractures Among Older Females With Bisphosphonate Exposure.

Bisphosphonates (BP) are used to treat osteoporosis, although rare atypical femur fractures have occurred with long-term exposure, especially among Asians. Metatarsal fractures have also been reported with atypical femur fracture. We examined the epidemiology of metatarsal fractures among 48,390 females aged ≥50 years who initiated oral BP and were followed for a median 7.7 years, including 68 females who experienced an atypical femur fracture. Incident metatarsal fractures after BP initiation were identified by clinical diagnoses and validated by record review. The association of BP, clinical risk factors, race/ethnicity, and metatarsal fracture was examined by using Cox proportional hazard analyses. Among 1123 females with incident metatarsal fracture, 61.0% had an isolated fifth metatarsal fracture. The incidence of metatarsal fracture was 312 per 100,000 person-years of follow-up and was substantially lower for Asians. The adjusted relative rate for metatarsal fractures was 0.5 (95% confidence interval 0.4 to 0.6) for Asians compared with whites. Younger age, prior fracture, other risk factors, and current BP were associated with an increased relative rate of metatarsal fracture, but BP duration was not. Females with atypical femur fracture were not more likely to experience metatarsal fracture (2.9% versus 2.3%, p = .7), but only 68 females had an atypical fracture and stress fracture of the metatarsals was not examined. Except for age, the demographic profile for metatarsal fracture after initiating BP was similar to that for osteoporotic fracture, with Asians at a much lower risk. Although metatarsal fractures were not associated with BP duration or atypical femur fracture, the subset of metatarsal stress fractures was not specifically examined.

Three-Year Morbidity and Mortality Rates After Nontraumatic Transmetatarsal Amputation.

Patients requiring a nontraumatic transmetatarsal amputation (TMA) typically have multiple comorbidities that place them at high risk of postoperative complications and additional surgery. The present study identified the demographic, clinical, and surgical risk factors that predict complications after a nontraumatic TMA, including the incidence of 3-year mortality, proximal limb amputation, and lack of healing. The electronic medical records of patients who had undergone TMA within a Kaiser Permanente Northern California facility from March 2007 to January 2012 (n = 375) were reviewed. We used bivariate and multivariate analyses to examine the variations in the rates of TMA complications according to sex, age, race, and comorbid conditions, including nonpalpable pedal pulses, end-stage renal disease, coronary artery disease, hypertension, smoking status, and preoperative albumin <3.5 mg/dL. After a nontraumatic TMA, 136 (36.3%) patients had died within 3 years, 138 (36.8%) had required a more proximal limb amputation, and 83 (22.1%) had healed without complications. The patients with nonpalpable pedal pulses had 3 times the odds of requiring a proximal limb amputation (adjusted odds ratio [aOR] 3.07; 95% confidence interval [CI] 1.84 to 5.11), almost twice the odds of dying within 3 years (aOR 1.70; 95% CI 0.98 to 2.93), and >2 times the odds of not healing after the TMA (aOR 2.45; 95% CI 1.40 to 4.31). The patients with end-stage renal disease had 3 times the odds of dying within 3 years (aOR 3.10; 95% CI 1.69 to 5.70). The present findings can help us identify patients with an increased risk of postoperative complications after nontraumatic TMA, including patients with nonpalpable pedal pulses or end-stage renal disease, and suggest the vulnerability of this patient population.

The Neglected Achilles Tendon Rupture Repaired With Allograft: A Review of 14 Cases.

Various surgical techniques have been reported for the repair of neglected Achilles tendon ruptures, including V-Y advancements, synthetic augmentations, and collagen implants. The use of an Achilles tendon allograft allows bridging of large defects without donor site morbidity, with a relative ease of technique and adequate graft availability. The present retrospective report focused on the outcomes of a series of 14 patients with neglected ruptures treated with an Achilles tendon allograft. Patients were included in the present series if they had ≥12 months of postoperative follow-up data available and the allograft had been used without any adjunctive procedures. Of the 14 patients, 6 were female (43%) and 8 were male (57%), with a mean follow-up period of 16.1 ± 3 (range 12 to 27) months. The mean interval from the initial injury to surgery was 6.9 ± 5 (range 1 to 28) months. The mean intraoperative defect size was 7.0 ± 3 (range 4 to 15) cm. A calcaneal block was used in 2 patients (14%). All patients were able to perform a single heel rise at a mean of 27 ± 11 (range 12 to 37) weeks postoperatively. Weightbearing in normal shoe gear was achieved at a mean of 13.5 ± 3 (range 12 to 17) weeks. Complications included 1 delayed union (7%) of the calcaneal bone block. Repair of the neglected Achilles tendon rupture with an allograft appears to be an acceptable approach, with good overall outcomes and low risk. These results suggest that this method of repair compares favorably with established alternatives.

Bicortical fixation of medial malleolar fractures: a review of 23 cases at risk for complicated bone healing.

Several methods have been described for fixation of unstable medial malleolar fractures. Certain patient populations, including the elderly, those with osteoporosis and osteopenia, and patients with diabetes mellitus, are generally known to be susceptible to complications associated with ankle fracture healing. The goal of the present retrospective investigation was to review the outcomes of a series of patients who had undergone medial malleolar fracture repair using fully threaded bicortical interfragmental compression screw fixation. Patients were included in the present series if they had undergone bicortical fixation of an unstable ankle fracture with a medial malleolar fracture component, in addition to having at least 1 of the following comorbidities: age 55 years or older, osteoporosis or osteopenia, diabetes mellitus, peripheral arterial disease, end-stage renal disease, chronic kidney disease, previous kidney transplantation, peripheral neuropathy, or current tobacco use. A total of 23 ankle fractures in 22 consecutive patients met the inclusion criteria. The mean age of the patients was 69.52 (range 45 to 89) years; 17 were female (77.27%) and 5 were male (22.73%). Of the 23 medial malleolar fractures, 21 (91.3%) achieved complete, uncomplicated healing. The mean interval to union was 62.6 (range 42 to 156) days. A total of 4 complications (17.39%) were noted, including 1 nonunion (4.35%), 1 malunion (4.35%), and 2 cases of painful retained hardware (8.7%). From our experience with this series of patients, bicortical screw fixation for medial malleolus fractures appears to be an acceptable alternative for fixation that provides a stable construct for patients at greater risk of bone healing complications.

Comparison of pullout strength between 3.5-mm fully threaded, bicortical screws and 4.0-mm partially threaded, cancellous screws in the fixation of medial malleolar fractures.

Displaced medial malleolus fractures are considered unstable and typically require open reduction and internal fixation for anatomic reduction and early joint range of motion. These fractures are usually fixated with either compression lag screws or tension band wiring depending on the fracture pattern, size of the distal fragment, and bone quality. When fracture fixation fails, it is typically in pullout strength. Failure of primary bone healing can result in nonunion, malunion, and need for revision surgery. The current study wished to explore a potentially stronger fixation technique in regard to pullout strength for medial malleolar fractures compared with traditional cancellous screws. This was a comparative study of the relative pullout strength of 2 fully threaded 3.5-mm bicortical screws versus 2 partially threaded 4.0-mm cancellous screws for the fixation of medial malleolar fractures. Ten fresh-frozen limbs from 5 cadavers, mean age 79 years (range of 65-97 years), were tested using the Instron 8500 Plus system. The median force recorded at 2 mm of distraction using unicortical partially threaded cancellous screws was 116.2 N (range 70.2 to 355.5N) compared with 327.6 N (range 117.5 to 804.3 N) in the fully threaded bicortical screw (P = .04). The unicortical screw fixation displayed only 64.53% of the median strength noted with the bicortical screw fixation at clinical failure. The current study demonstrated statistically significantly greater pullout strength for 3.5-mm bicortical screws when compared with 4.0-mm partially threaded cancellous screws used to fixate medial malleolar fractures in a cadaveric model.

Posterior bone block distraction arthrodesis of the subtalar joint: a review of 22 cases.

UNLABELLED: Twenty-two patients underwent a posterior bone block distraction arthrodesis of the subtalar joint between 1999 and 2006. The indication for surgery was loss of heel height, subtalar joint arthrosis, decreased talar declination with associated tibiotalar impingement, insufficient Achilles tendon function, malalignment of the rear foot, and pain with ambulation. There were 11 male and 11 female patients with a mean age of 46.7 years (range 20 to 71). The mean follow-up period was 27.3 months (range 12 to 63.9 months). Radiographic analysis revealed a mean increase in heel height of 6.09 mm (P= .0001), 5.83 degrees (P= .12) of lateral talocalcaneal angle, 5.5 degrees (P= .06) of talar declination, and 5.23 degrees (P= .07) of calcaneal inclination. The talo-first metatarsal angle increased an average of 4.5 degrees (P= .18). There was a 95.5% union rate. Postoperative complications included nonunion in 1 patient, subsidence of graft (collapse) in 1 patient, wound dehiscence in 3 patients, painful hardware in 7 patients, sural neuritis in 1 patient, superior cluneal nerve dysfunction in 1 patient and one mild varus malunion. Posterior bone block distraction arthrodesis can be successfully used to restore heel height, realign the foot, and decrease the morbidity associated with late complications of calcaneal fractures, as well as, nonunion and/or malunion following subtalar joint arthrodesis, Charcot neuroarthropathy, and avascular necrosis of the talus. LEVEL OF CLINICAL EVIDENCE: 4.