Technique using interference fixation repair for plantar plate ligament disruption of lesser metatarsophalangeal joints.

Lesser metatarsophalangeal joint instability is a challenging disorder for the foot and ankle surgeon to repair. We believe that disruption of the plantar plate is common, and its repair should be carefully considered. However, we believe that most current techniques inadequately address repair of the complete plantar plate ligament tear, and, thus, instability and pain commonly persist after disruption of the plantar plate. In the present report, we present a technique we have found useful for repair of a complete plantar plate ligament rupture. The method we have described uses interference screw fixation through a dorsal incision to stabilize the lesser metatarsophalangeal joint.

Retrospective comparative study of operative repair of hammertoe deformity.

BACKGROUND: The purpose of this study was to compare the outcomes of patients with second hammertoe deformities who underwent correction using either joint resection arthroplasty, proximal interphalangeal joint (PIP) arthrodesis without osteotomy, or interpositional implant arthroplasty. METHODS: Medical records from patients who underwent second PIP correction from July 1999 to December 2008 were retrospectively reviewed. A total of 114 patients (136 second toes) were the basis for this retrospective comparative study. The average final follow-up with weight-bearing radiographs of the 136 procedures at the second toe was 53.8 months. RESULTS: All 3 groups had significantly reduced VAS scores postoperatively (P < .01). Also, all groups had significant radiographic correction in the average measured lateral angle of the second PIP joint (P < .01). However, the interpositional implant group had significantly corrected the second PIP joint in the axial plane, with an average postoperative anterior-posterior (AP) angle of 2.9° (P < .01). The postoperative AP angle was also significantly different compared with the postoperative AP angles of the other 2 groups (P < .01). DISCUSSION: Our study confirms that all 3 techniques provide adequate pain relief and radiographic sagittal plane correction. However, interpositional implant arthroplasty provides significant radiographic correction in the axial plane. LEVELS OF EVIDENCE: Therapeutic Level III, Retrospective comparative study.

Retrospective analysis of mini-open repair versus open repair for acute Achilles tendon ruptures.

PURPOSE: Debate exists over optimal treatment for acute Achilles tendon ruptures. Recent literature suggests the mini-open technique may provide the reliability of the open repair with the decreased complication rate of non-operative treatment. This retrospective review compares acute tendon ruptures treated with one of two techniques: open repair (TO) or mini-open repair (MOA). METHODS & RESULTS: Records were reviewed and 34 patients were found to meet the inclusion criteria for open or mini-open repair of an acute Achilles tendon rupture with follow up of at least 12 months. TO (n=16) and MOA (n=18) had no statistically significant differences in age at time of injury [TO: 41 + 2.5 years (range 20 - 68); MOA: 46 + 2.5 years (range 33 - 73)] or time between injury and surgical repair [TO: 15 + 2 days (range 2 - 30); MOA: 15 + 2 days (range 2 - 30)]. Post-operative VISA-A scores were 82 + 10 (range 42 - 98) and 92 + 5 (range 66 - 100) for TO and MOA, respectively. Significant differences were found in the time between surgical intervention and beginning of rehabilitation [TO: Post op day 37 + 5 (range 21 - 46); MOA: Post op day 19 + 2 (range 7 - 32)] and the time between surgical intervention and full return to activity [TO: Post op month 7 + 1 (range 4 - 11); MOA: Post op month 5 + 0.6 (range 4 - 11)]. CONCLUSION: These results suggest that the mini-open repair provides acceptable surgical outcomes while optimizing patient function after Achilles tendon repair.

Diagnosis of plantar plate injury by magnetic resonance imaging with reference to intraoperative findings.

The objective of the present study was to assess the utility of magnetic resonance imaging in evaluating injury to the plantar plate and to determine whether conventional low-field magnetic resonance imaging is a valid tool for diagnostic evaluation. Magnetic resonance imaging scans of 45 feet in 41 patients (38 females and 3 males, with an average age of 52.1 years) were prospectively evaluated to assess the integrity of the plantar plate ligament and compared with a reference standard of intraoperative findings. The concordance of tear severity observed on magnetic resonance imaging with the intraoperative findings was also assessed using a newly proposed grading scheme for plantar plate injuries. Intraoperatively, 41 plantar plate tears and 4 intact ligaments were found. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value was 96%, 95%, 100%, 100%, and 67%, respectively. The clinical diagnosis of plantar plate injury was also highly accurate in our study population (41/45, 91%). Finally, we observed moderate concordance between the magnetic resonance imaging grade and surgical grade of plantar plate tear (28/45, 62%), with greater concordance occurring at higher grades. Our results have demonstrated that magnetic resonance imaging is an accurate and valid test for the diagnosing injuries of the plantar plate ligament. Given the high accuracy of the clinical findings, magnetic resonance imaging is most useful when the decision to operate will be sufficiently influenced by either a normal magnetic resonance imaging appearance of the plantar plate or the presence of a high-grade tear.

Subtalar arthroereisis.

Arthroereisis has gained popularity over the years because it eliminates excessive pronation while conserving preoperative inversion and preserves forefoot to rearfoot adaptation to uneven terain. Technically simple, some of the advantages of subtalar arthroereisis are that it is joint sparing and preserves ligaments. In addition, the implant does not interfere with osseous growth and does not compromise future operative intervention if more invasive procedures are required. Arthroereisis, however, can have associated complications along with the need for surgical removal in some patient populations.

Total first metatarsophalangeal joint implant arthroplasty: a 30-year retrospective.

The first metatarsophalangeal (MTP) joint is a frequent diseased-affected articulation encountered by the foot and ankle surgeon. Arthroplasty remains a favorable option for surgeons, because it preserves motion of the joint. The authors' focus at the Weil Foot and Ankle Institute has been on using double-stem silicone implants with titanium grommets, which may be a viable solution for affected articulations. The authors present their clinical results from over 30 years of experience with total first MTP joint implant arthroplasty at the Weil Foot and Ankle Institute.

Anatomic plantar plate repair using the Weil metatarsal osteotomy approach.

The purpose of this study was to analyze the early results of a new technique for anatomic plantar plate repair and advancement using a Weil metatarsal osteotomy of the second metatarsal. The authors retrospectively reviewed medical records of 13 consecutive adult patients (15 feet) who underwent this procedure by a single surgeon. The authors recorded visual analog pain scale scores preoperatively and postoperatively and patient-reported clinical outcome measurement surveys during their final follow-up visit. At an average of 22.5 months (range, 13 to 33 months) follow-up, 11 of 13 patients (85%) reported improved function whereas 10 of 13 (77%) were either satisfied or very satisfied with the outcome. Postoperative scores on the American Orthopaedic Foot and Ankle Society Lesser Metatarsophalangeal- Interphalangeal Scale averaged 85.7 on a scale of 100 (SD = 13.1, 95% CI = 79.1-91.5). Patients reported an average preoperative visual analog pain scale of 7.3 (SD = 1.6, 95% CI = 6.4-8.1) versus an average of 1.7 (SD = 1.8, 95% CI = 0.7-2.7) postoperatively. This was a significant reduction in pain rating (P < .0001, t = 8.9, df = 27). Complications included painful hardware and metatarsalgia. There were no cases of dehiscence, malunion, nonunion, or recurrent metatarsophalangeal joint subluxation. This unique surgical technique addresses metatarsal overload and the instability of the second metatarsophalangeal joint while allowing for anatomic repair of the plantar plate pathology.

Technical guide: transfibular ankle arthrodesis with fibular-onlay strut graft.

A wide range of techniques have been described for ankle arthrodesis, and although all of these have been shown to provide stability, few have been shown to achieve a solid construct in patients at risk of nonunion. In this technical guide, we describe a modified transfibular approach to ankle arthrodesis that uses a fibular-onlay strut graft for use in patients at high risk for nonunion. In our experience, the technique has been effective and reliable.

Subungual squamous cell carcinoma after organ transplantation.

It is accepted that immunosuppressant therapy after organ transplantation is associated with an increase risk of neoplasm. Subungual squamous cell carcinoma of the toe is a rare condition and has not previously been reported, to our knowledge, in patients undergoing immunosuppressant therapy. The objective of this case study is to report the clinical and histopathologic findings and the multidisciplinary treatment approach for a case of subungual squamous cell carcinoma of the toe in an organ transplant recipient undergoing immunosuppressant drug therapy.

Radiographic outcomes following primary arthrodesis of the first metatarsophalangeal joint in hallux abductovalgus deformity.

The purpose of this study was to evaluate the radiographic outcomes of primary metatarsophalangeal joint arthrodesis for hallux abductovalgus deformities. Between January 2004 and March 2009, 56 consecutive patients (58 feet) underwent primary arthrodesis of the metatarsophalangeal joint (MTPJ) for severe hallux abductovalgus deformity and or hallux rigidus. Results were assessed by primary radiographic outcome measurements (hallux valgus and first-second intermetatarsal angle). Overall, the mean hallux valgus (HA) angle improved significantly from 31.9 degrees to 13.4 degrees (P < .01). The mean first-second intermetatarsal (IM) angle correction was also significantly reduced from 14.0 degrees to 9.7 degrees (P < .01). When separated by deformity group (mild, moderate, and severe), the mean hallux valgus and first-second intermetatarsal angles demonstrated statistically significant correction in all groups when comparing preoperative and postoperative values (P < .01). Primary arthrodesis provides predictable radiographic outcomes and effective correction for patients with differing severity of hallux abductovalgus deformity and arthritis of the first metatarsophalangeal joint. A separate proximal osteotomy for severe metatarsus primus varus correction may not be necessary because of the correction achieved at the metatarsophalangeal joint arthrodesis level. The results of this study demonstrate that as the severity of the preoperative deformity increases, the amount of postoperative radiographic (HA and IM angle measurement) correction after MTPJ arthrodesis will improve correspondingly.

Charcot arthropathy of the foot and ankle: modern concepts and management review.

Charcot arthropathy (Charcot neuroarthropathy, diabetic neuropathic osteoarthropathy, or neuropathic arthropathy) remains a poorly understood disease, although recent research has improved our level of knowledge regarding its etiology and treatment. The effects of Charcot arthropathy are almost exclusively seen in the foot and ankle, and the diagnosis is commonly missed upon initial presentation. It has been well established that this complication of diabetes mellitus severely reduces the overall quality of life and dramatically increases the morbidity and mortality of patients. However, there are few high-level evidence studies to support management and treatment options at this point in time. The goal of this study is to evaluate the modern concepts of Charcot arthropathy through a review of the available literature and to integrate a perspective of management from the authors' extensive experience.