Flexor Digitorum Longus Tendon Transfer and Modified Kidner Technique in Posterior Tibial Tendon Dysfunction.

The modified Kidner procedure and flexor digitorum longus tendon transfer are common procedures used today when addressing posterior tibial tendon dysfunction. These techniques are often used in conjunction with a combination of osteotomies to correct flatfoot deformity, and have been proved to be reliable and predictable.

Subtle cavus foot: diagnosis and management.

The subtle cavovarus foot (SCF) is a mild malalignment caused by either primary hindfoot varus or a plantarflexed first ray, resulting in a typical constellation of symptoms because of altered foot mechanics. Key clinical signs are a peek-a-boo heel and a positive Coleman block test. The cavovarus position places lateral ankle soft-tissue structures, such as the anterior talofibular ligament and the peroneal tendons, on stretch during normal gait. This can lead to common conditions such as lateral ankle instability, peroneal tendon tears, and stress fractures of the lateral metatarsals and cuboid. The gait cycle is altered because a greater proportion of time is spent with the transverse tarsal joints locked due to the overall varus foot position. In contradistinction to physiologic valgus at heel strike, which maintains the transverse tarsal joints unlocked and affords approximately 50% force dissipation, the increased rigidity of the foot causes a maldistribution of forces that leads to accelerated wear of the midfoot joints and increased stresses along the plantar fascia and the Achilles tendon insertion. Successful nonsurgical management requires correction of the biomechanical anomaly; surgical management of a subtle cavovarus foot typically is part of a comprehensive plan for correcting the symptoms and the malalignment.

Surgical management and treatment algorithm for the subtle cavovarus foot.

BACKGROUND: Subtle cavovarus foot is a condition that can lead to significant foot pain and disability. We review the results of our treatment algorithm at medium-term followup. MATERIALS AND METHODS: Thirty-five consecutive patients with lateral based symptoms due to an underlying congenital subtle cavovarus foot type were surgically corrected. Various procedures were utilized, including some combination of the following: lateral displacement calcaneus osteotomy, peroneus longus to brevis transfer, dorsiflexion first metatarsal osteotomy, and Achilles tendon lengthening. Twenty-three patients, with 29 feet, returned for followup examination. The mean patient age at the time of surgery was 43.4 years, and the mean followup to date was 4.4 years. RESULTS: The mean AOFAS ankle hindfoot score preoperatively was 45, and postoperatively was 90. Radiographically, the medial cuneiform to floor height changed from 3.5 cm preoperatively to 3.0 cm postoperatively. The talo-first metatarsal angle improved 7.5 degrees postoperatively. There were no nonunions. No patients to date have gone on to fusions or revisions. Ten feet (34%) required hardware removal. All patients had resolution of their symptoms following hardware removal. CONCLUSION: The surgical management for the subtle cavovarus foot based on the proposed treatment algorithm provided symptomatic relief, longstanding correction, and high patient satisfaction.

Transfibular ankle arthrodesis with rigid internal fixation: an assessment of outcome.

BACKGROUND: Transfibular ankle arthrodesis with internal fixation and fibular onlay grafting has resulted in acceptable fusion rates. This study analyzed the results of ankle arthrodesis using one operative technique in a large series of patients with high and low risks for nonunions. METHODS: Fifty consecutive patients had a transfibular ankle arthrodesis with rigid internal fixation and fibular onlay strut grafting from 1997 to 2004. Two patients were lost to followup. The remaining 48 patients had preoperative and postoperative clinical and radiographic examinations and then were stratified into high-risk and low-risk groups for ankle nonunions. Fifteen of 48 patients were considered at high risk for nonunion. Rate of osseous fusion, satisfaction with the procedure, correction of the deformity, and relief of pain were evaluated. Thirty-five of 48 patients were evaluated with the AOFAS ankle-hindfoot scale at an average 45 months after surgery. RESULTS: Forty-six of 48 patients had bony union (96% union rate). Fourteen of 15 (93%) high-risk patients had bony fusion in an average of 83 days. Thirty-two of 33 patients (97%) in the low-risk group had bony fusion at an average of 81 days. The AOFAS ankle-hindfoot score improved from 38 to 74 in 12 of 15 patients in the high-risk group and from 34 to 69 in 24 of 33 patients in the low-risk group from preoperative to postoperative scores. CONCLUSIONS: A transfibular ankle arthrodesis with rigid internal fixation and fibular onlay strut grafting can achieve a high rate of union in both a low-risk and high-risk patient populations. This technique can be an effective approach for most primary and revision cases with or without significant deformity. In addition the AOFAS ankle-hindfoot score improved significantly both in the high-risk and low-risk groups.

The use of autologous concentrated growth factors to promote syndesmosis fusion in the Agility total ankle replacement. A preliminary study.

BACKGROUND: The Agility (DePuy, Warsaw, Indiana) total ankle replacement has been in use since 1984. One of the most common complications continues to be delayed union or nonunions of the distal tibiofibular syndesmosis. In the reported studies on the Agility ankle the delayed union and nonunion rate can be as high as 38%. METHODS: Since 1999, 114 Agility total ankle replacements were done at two centers in the United States without the use of autologous concentrated growth factors. Since July of 2001, 66 Agility ankles were implanted with Symphony (DePuy, Warsaw, Indiana) augmented bone grafting. The standard operative technique was followed in all the patients. Prospective data was collected on all patients. The standard ankle radiographs were taken preoperatively and postoperative at 8 weeks, 12 weeks, 16 weeks, 6 months, and yearly. CT scans were obtained at 6 months if fusion at the syndesmosis was questionable. The Graphpad Instat software (Graphpad Software Inc., San Diego, CA) was used for statistical analysis. The two-tailed unpaired t-test was used, and the value <0.05 was considered significant. RESULTS: There was no statistical difference in the demographic data for the two groups. In 114 ankle replacements without autologous concentrated growth factors 70 fused at 8 weeks (61%), 14 fused at 12 weeks (12%), 13 fused at 6 months (12%). There were 17 nonunions (15%); delayed unions (3 to 6 months) and nonunions, therefore, equaled 27%. The syndesmosis fused in 50 of the 66 ankle replacements (76%) that had autologous concentrated growth fractures at 8 weeks (76%); 12 fused at 3 months (18%), 2 fused at 6 months (3%), 2 had nonunions (3%). Delayed unions (3 to 6 months) and nonunions equaled 6%. There was a statistically significant improvement in the 8- and 12-week fusion rates, and a statistically significant reduction in delayed unions and nonunions. CONCLUSION: Autologous concentrated growth factors appear to make a significant positive difference in the syndesmosis union rate in total ankle replacements.

Enhancement of syndesmotic fusion rates in total ankle arthroplasty with the use of autologous platelet concentrate.

BACKGROUND: One of the challenges of total ankle arthroplasty continues to be achieving a solid distal fusion of the tibiofibular joint. Delayed union rates of 29% to 38% and the nonunion rates of 9% to 18% for syndesmotic fusion have been documented. The risk of tibial component migration has been reported to increase 8.5 times if a solid syndesmotic fusion is absent. Growth factors have been shown to accelerate bone healing and may enhance the fusion of the syndesmosis and, thereby, decrease the frequency of nonunion and subsequent tibial component migration. METHODS: An autologous platelet concentrate was used to increase the amount of growth factors at the site of the distal tibiofibular joint fusion in 20 total ankle arthroplasties. RESULTS: Our 6-month fusion rate was 100%. When compared to historical controls (6-month fusion rate of 62%) the difference was statistically significant (p < 0.0001). CONCLUSION: The improved rate of distal tibiofibular fusion may be attributable to the increased presence of growth factors provided by an autologous platelet concentrate.