Republication of "Congenital Dislocation of the Fifth Metatarsophalangeal Joint in Adults: Operative Technique"

Congenital dislocation of the fifth metatarsophalangeal (MTP) joint can cause significant limitations in a patient's ability to wear a closed shoe. Historic treatment has involved amputation of the digit or attempts at reconstruction. These techniques have had limited success with unreliable correction and/or unacceptable cosmesis. The authors present a detailed, methodical approach to reconstruction of this deformity with a stepwise algorithm that addresses both the bony and soft tissue components of the deformity. With this modern technique, reliable and satisfactory results can be expected.

Summary Report of the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society's Symposium on Targets for Osteoarthritis Research: Part 1: Epidemiology, Pathophysiology, and Current Imaging Approaches

This first of a 2-part series of articles recounts the key points presented in a collaborative symposium sponsored jointly by the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society with the intent to survey the state of scientific knowledge related to incidence, diagnosis, pathologic mechanisms, and injection treatment options for osteoarthritis (OA) of the foot and ankle. A meeting was held virtually on December 3, 2021. A group of experts were invited to present brief synopses of the current state of knowledge and research in this area. Part 1 overviews areas of epidemiology and pathophysiology, current approaches in imaging, diagnostic and therapeutic injections, and genetics. Opportunities for future research are discussed. The OA scientific community, including funding agencies, academia, industry, and regulatory agencies, must recognize the needs of patients that suffer from arthritis of foot and ankle. The foot and ankle contain a myriad of interrelated joints and tissues that together provide a critical functionality. When this functionality is compromised by OA, significant disability results, yet the foot and ankle are generally understudied by the research community. Level of Evidence: Level V - Review Article/Expert Opinion.

Summary Report of the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society's Symposium on Targets for Osteoarthritis Research: Part 2: Treatment Options

This second of a 2-part series of articles recounts the key points presented in a collaborative symposium sponsored jointly by the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society with the intent to survey current treatment options for osteoarthritis (OA) of the foot and ankle. A meeting was held virtually on December 10, 2021. A group of experts were invited to present brief synopses of the current state of knowledge and research in this area. Topics were chosen by meeting organizers, who then identified and invited the expert speakers. Part 2 overviews the current treatment options, including orthotics, non-joint destructive procedures, as well as arthroscopies and arthroplasties in ankles and feet. Opportunities for future research are also discussed, such as developments in surgical options for ankle and the first metatarsophalangeal joint. The OA scientific community, including funding agencies, academia, industry, and regulatory agencies, must recognize the importance to patients of addressing the foot and ankle with improved basic, translational, and clinical research.

LEVEL OF EVIDENCE

Level V, review article/expert opinion.

Preoperative Gait Analysis of Peroneal Tendon Tears

BACKGROUND

Little is known regarding the impact of peroneal tendon tears on function. This study quantifies gait changes associated with operatively-confirmed peroneal tendon tears.

METHODS

Sixty-five patients with unilateral peroneal tendon tears were prospectively evaluated using preoperative 3D multisegment gait analysis of both limbs. Data were analyzed according to pattern/severity of tears, as confirmed surgically: peroneus brevis tears, reparable (PBR); peroneus brevis tears, irreparable (PBI); peroneus longus tears, irreparable (PLI); and concomitant irreparable tears of both tendons (PBI+PLI). The following parameters were analyzed: ankle sagittal motion, coronal motion, axial rotation, foot progression angle, sagittal power, sagittal moment.

RESULTS

Twelve patients (18.5%) had the PBR pattern, 37 (56.9%) PBI, 10 (15.4%) PLI, and 6 (9.2%) PBI+PLI. Compared with the contralateral, nonpathologic extremities, limbs with peroneal tears had diminished ankle sagittal motion (mean 23.14 vs 24.30 degrees, P = .012), ankle/hindfoot axial rotation (6.26 vs 7.23 degrees, P = .001), sagittal moment (1.16 vs 1.29 Nm/kg, P < .001), and sagittal power (1.24 vs 1.47 W/kg, P < .001). The most severe tear patterns had the greatest derangements in multiple parameters of gait (PBI+PLI > PBI or PLI > PBR). For example, all groups except PBR had loss of ankle sagittal moment and/or power in the affected limb, and the greatest losses in moment and power were in the PBI+PLI group (1.22 vs 0.91 Nm/kg, P = .003 for moment; 0.73 vs 1.31 W/kg, P < .001 for power). The PBI+PLI group had a >10-degree varus shift in coronal motion on the affected side (P = .002).

CONCLUSION

This is the first study to demonstrate diminished biomechanical function in patients with peroneal tendon tears. In vivo 3-dimensional gait analysis found significant changes in hindfoot motion, ankle motion, and ankle power. Impairments were related to the pattern and severity of the tears, and demonstrated a strong association of peroneal tendon tears with diminished ankle plantarflexion strength.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Allograft Reconstruction for Unsalvageable and Recurrent Tears of Both Peroneal Tendons

Category:

Ankle; Hindfoot; Sports

Introduction/Purpose:

Surgical reconstruction for the complete loss of both peroneal tendons is challenging, with no established standard. This is true both for concomitant tears that extend superior to the superior peroneal retinaculum, and for nonfunctioning, unsalvageable peroneal tendons after prior repair or reconstruction, which have recurrent tears, tendon degeneration, scarring, and stretching. These cases have in common that there is no option for retention of the native tendons. Allograft reconstruction can bridge long defects, reestablishing the insertion of the proximal musculo-tendinous unit to the lateral foot. However, there are limited published data on allograft reconstruction, and series are small and heterogenous. This study reports the results of allograft reconstruction at a mean of 4.1 years follow-up (range 1.5-7.3 years).

Methods:

A retrospective study reviewed patients who had allograft reconstruction for unsalvageable or recurrent tears of both the peroneus brevis and peroneus longus tendons. In all cases, the unsalvageable segments of both peroneal tendons were excised. A hamstring allograft tendon with width of >6mm was pre-stretched, then anchored to the proximal 5thmetatarsal, and also sutured to itself and the adjacent brevis stump, if viable. The peroneal retinaculae were reconstructed over the allograft tendon. The peroneal muscle-proximal tendon units were extensively stretched inferiorly using suture loops in the tendons. They were maximally tensioned and anastomosed to the maximally tensioned allograft while holding the hindfoot in maximum eversion. Of the 14 eligible patients, 13 had minimum one-year follow-up and constituted the study population. Mean age was 50.7 years (range 26.3-68.6 years). Ten patients had at least one prior peroneal tendon surgery; four patients had at least two.

Results:

At mean follow-up of 4.1-years, seven patients were 'very satisfied,' one 'satisfied,' one 'neutral,' and two 'dissatisfied.' Ten stated they would have the procedure again, one would not. Two could not be reached to answer these questions. Visual analogue scale pain score decreased from 4.6 to 3.4 (p=0.150), ankle osteoarthritis scale (AOS) pain subscale decreased from 36.2 to 13.8 (p=0.013), AOS disability subscale decreased from 42.8 to 21.9 (p=0.032), and AOS total score decreased from 39.5 to 17.8 (p=0.014). No statistical change in SF-36 physical function score (p=0.547) or PROMIS physical function score (p=0.580) was detected. At last examination, 12 of 13 patients had active eversion and a palpable, tensioned graft. The patient without active eversion underwent triple arthrodesis; no other patient had additional peroneal or hindfoot surgery.

Conclusion:

Allograft interposition is effective to reconstruct unsalvageable concomitant tears of both peroneal tendons as well as the most difficult revision cases of nonfunctioning, unsalvageable peroneal tendons after prior repair or reconstruction, which have recurrent tears, tendon degeneration, scarring, and stretching. There is a high rate of restoration of peroneal function, a reasonable rate of patient satisfaction, and statistically significant improvements in ankle-specific patient-reported outcomes.

Association of Cavovarus Foot Alignment With Peroneal Tendon Tears

BACKGROUND

Although it is a widely accepted clinical principle that cavovarus deformity predisposes to peroneal tendon problems, there are limited data to support that assumption. This study tested the hypothesis that cavovarus is associated with peroneal tendon tears and evaluated which radiographic measures correlated with that association.

METHODS

A retrospective comparison of radiographic measures of cavovarus in 234 consecutive patients operatively treated for chronically symptomatic peroneal tendon tears was compared to a matched control group. Measures included calcaneal pitch, anteroposterior (AP) talometatarsal and talocalcaneal angles, and talonavicular coverage angle. A novel coordinate system analyzed midfoot and hindfoot components of cavovarus. Analysis of variance was used to compare cohorts, and a Tukey-Kramer test used to analyze 3 subgroups of brevis and longus tears, and concomitant tears.

RESULTS

The distribution of tears was 73% peroneus brevis, 8% longus, and 19% both tendons. Compared with controls, the study group, and subgroups, had multiple measures of increased cavovarus, including greater calcaneal pitch (P = .0001), decreased AP talo-first metatarsal angle (P = .0001), and increased talonavicular coverage angle (P = .0001). Elevated medial longitudinal arch, and rotational changes in the radiographic profiles of the hindfoot were found with the coordinate system described by Yokokura.

CONCLUSION

This study found a statistically significant association of increased cavovarus deformity with peroneal tendon tears, compared to controls. It documented the relative incidence of tears of peroneus brevis, peroneus longus, and concomitant tears in a large surgical series. It demonstrated which simple radiographic angles and complex coordinate measurements of cavovarus deformity were significantly associated with peroneal tendon tears.

LEVEL OF EVIDENCE

Level III, retrospective comparative cohort study.

Correlation of Patient-Reported Outcomes With Physical Function After Total Ankle Arthroplasty

BACKGROUND

Total ankle arthroplasty (TAA) is successful by both subjective patient-reported outcome measures (PROMs) and objective functional improvements of gait. Each is reproducible and valid, but they are entirely distinct methods. This study investigated the correlation between subjective and objective outcomes of TAA.

METHODS

Seventy patients underwent gait analysis preoperatively and 1 year after TAA. The 36-Item Short-Form Health Survey (SF-36) and visual analog score (VAS) for pain and American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scores were recorded at each interval. A Student t test, a multivariate regression, and a Pearson correlation coefficient were used to measure the correlation between parameters of gait and PROMs.

RESULTS

Patients had statistically significant improvements in gait velocity, total range of motion (ROM), maximum plantarflexion, ankle power, and SF-36 Physical, VAS, and AOFAS scores. The SF-36 Physical score had a moderate positive correlation with preoperative walking speed, step length, and ankle power and postoperative walking speed and ankle power. No correlation between VAS score and function was detected. The AOFAS score had a moderate positive correlation with postoperative walking speed, step length, and ankle power, and improvement in walking speed, cadence, and ankle power.

CONCLUSION

Statistically significant correlations were found between numerous preoperative and postoperative comparisons of PROMs and the AOFAS score with the objective biomechanical outcomes of gait. Walking speed and ankle push-off power correlated most with patient perceptions of function and improvement, while pain and ROM did not. Subjective PROMs and objective biomechanical outcomes were complementary in the assessment of surgical outcomes and, combined, helped to address the dilemma of the confounding effect of other lower extremity pathologies on PROMs.

LEVEL OF EVIDENCE

Level III, comparative series.

Long-term Functional Results of Total Ankle Arthroplasty in Stiff Ankles

BACKGROUND

Total ankle arthroplasty (TAA) is advocated over ankle arthrodesis to preserve ankle motion (ROM). Clinical and gait analysis studies have shown significant improvement after TAA. The role and outcomes of TAA in stiff ankles, which have little motion to be preserved, has been the subject of limited investigation. This investigation evaluated the mid- to long-term functional outcomes of TAA in stiff ankles.

METHODS

A retrospective study of prospectively collected functional gait data in 33 TAA patients at a mean of 7.6 (5-13) years postoperatively used 1-way analysis of variance and multivariate regression analysis to compare among preoperative and postoperative demographic data (age, gender, body mass index, years postsurgery, and diagnosis) and gait parameters according to quartiles of preoperative sagittal ROM.

RESULTS

The stiffest ankles had a mean ROM of 7.8 degrees, compared to 14.3 degrees for the middle 2 quartiles, and 21.0 degrees for the most flexible ankles. Patients in the lowest quartile (Q1) also had statistically significantly lower step length, speed, max plantarflexion, and power preoperatively. Postoperatively, they increased step length, speed, max plantarflexion, and ankle power to levels comparable to patients with more flexible ankles preoperatively (Q2, Q3, and Q4). They had the greatest absolute and relative increases in these parameters of any group, but the final total ROM was still statistically significantly the lowest.

CONCLUSION

Preoperative ROM was predictive of overall postoperative gait function at an average of 7.6 (range 5-13) years. Although greater preoperative sagittal ROM predicted greater postoperative ROM, the stiffest ankles showed the greatest percentage increase in ROM. Patients with the stiffest ankles had the greatest absolute and relative improvements in objective function after TAA, as measured by multiple gait parameters. At intermediate- to long-term follow-up, patients with stiff ankles maintained significant functional improvements after TAA.

LEVEL OF EVIDENCE

Level III, comparative study.

Functional Outcomes of Total Ankle Arthroplasty at a Mean Follow-up of 7.6 Years: A Prospective, 3-Dimensional Gait Analysis

BACKGROUND

In vivo gait analysis provides objective measurement of patient function and can quantify that function before and after ankle reconstruction. Previous gait studies have shown functional improvement for up to 4 years following total ankle arthroplasty (TAA), but to date, there are no published studies assessing function at ≥5 years following TAA. We hypothesized that patients who underwent TAA would show significant improvements in walking function at a minimum follow-up of 5 years, compared with their preoperative function, as measured by changes in temporospatial, kinematic, and kinetic gait parameters.

METHODS

Three-dimensional gait analysis with a 12-camera digital motion-capture system and double force plates was utilized to record temporospatial, kinematic, and kinetic measures in 33 patients who underwent TAA with either the Scandinavian Total Ankle Replacement (Stryker; n = 28) or Salto Talaris Ankle (Integra LifeSciences; n = 5). Gait analysis was performed preoperatively and at a minimum follow-up of 5 years (mean, 7.6 years; range, 5 to 13 years).

RESULTS

Significant improvements were observed in multiple gait parameters, with temporospatial increases in cadence (+9.5 steps/min; p < 0.0001), step length (+4.4 cm; p = 0.0013), and walking speed (+0.2 m/s; p < 0.0001), and kinematic increases in total sagittal range of motion (+2.0°; p = 0.0263), plantar flexion at initial contact (+2.7°; p = 0.0044), and maximum plantar flexion (+2.0°; p = 0.0488). Kinetic analysis revealed no loss of peak ankle power, despite patients aging.

CONCLUSIONS

To our knowledge, this is the first study to report 7-year functional outcomes of TAA, quantified by objective, in vivo measurements of patient gait. Patients were shown to have sustained improvement in multiple objective parameters of gait compared with preoperative function.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Arthrodesis of Ipsilateral Hallux Metatarsophalangeal and Interphalangeal Joints

Background:

Arthrodesis of the ipsilateral hallux metatarsophalangeal (MTP) and interphalangeal (IP) joints may be required for severe arthritis or deformity at both joints. The purpose of this study was to review outcomes of ipsilateral first MTP and IP joint arthrodesis.

Methods:

Twenty feet were identified, for which the diagnosis was rheumatoid arthritis in 14, failed hallux valgus surgery in 5, and hallux rigidus in 1. The IP arthrodesis was performed first in 6 feet; MTP first in 8 feet; and both joints simultaneously in 6 feet. Median follow-up was 28 months (range 12-94). Medical records and radiographs were reviewed. American Orthopaedic Foot & Ankle Society (AOFAS) score and patient satisfaction were determined.

Results:

Although all of the MTP arthrodeses healed, 8 of 20 feet (40%) failed to heal at the IP arthrodesis. The rate of IP nonunion was 17% (1/6) with IP arthrodesis first, 50% (4/8) with MTP arthrodesis first, and 50% (3/6) with simultaneous arthrodesis. Four of 8 IP nonunions were symptomatic. Subsequent surgery was required in 11 feet (55%), including repair of IP nonunion in 3 feet, hardware removal in 4, revision MTP malunion in 2, wound debridement in 1, and soft tissue reconstruction in 1. Median hallux AOFAS score for the cohort increased from 25 to 68. Eighteen feet resulted in patients who were very satisfied or satisfied with minor reservations. Neither AOFAS score nor satisfaction trended toward association with IP union.

Conclusion:

Ipsilateral arthrodesis of the hallux MTP and IP joints was challenging because of high rates of reoperation and IP nonunion, the latter of which was likely related to increased mechanical stress on the IP joint with immobilization of the MTP joint. Despite the high IP nonunion rate, IP nonunion did not predict patient-reported outcome. Fibrous ankylosis was an acceptable clinical outcome in many cases.

Level of Evidence:

Level IV, case series.

Diagnosis and Operative Treatment of Peroneal Tendon Tears

Peroneal tendon tears are a common but under-recognized source of ankle pain and dysfunction. Recognition of the characteristic symptoms, physical findings, and imaging results of peroneal tendon tears is essential for accurate diagnosis and appropriate treatment. Acute, limited tears of a single peroneal tendon may be debrided and repaired. However, by the time operative treatment is undertaken, many tears of a single tendon are sufficiently advanced that the surgeon may need to consider excision of the nonviable segment and tenodesis of the damged tendon to the to the adjacent peroneal tendon. Irreparable tearing of both peroneal tendons may be treated with flexor tendon transfer and/or allograft reconstruction. This review article focuses on diagnosis and operative treatment of peroneal tendon tears, including the treatment algorithms, operative technique, and published outcomes.

Diagnosis and Operative Treatment of Peroneal Tendon Tears

Peroneal tendon tears are a common but under-recognized source of ankle pain and dysfunction. Recognition of the characteristic symptoms, physical findings, and imaging results of peroneal tendon tears is essential for accurate diagnosis and appropriate treatment. Acute, limited tears of a single peroneal tendon may be debrided and repaired. However, by the time operative treatment is undertaken, many tears of a single tendon are sufficiently advanced that the surgeon may need to consider excision of the nonviable segment and tenodesis of the damged tendon to the to the adjacent peroneal tendon. Irreparable tearing of both peroneal tendons may be treated with flexor tendon transfer and/or allograft reconstruction. This review article focuses on diagnosis and operative treatment of peroneal tendon tears, including the treatment algorithms, operative technique, and published outcomes.

Congenital Dislocation of the Fifth Metatarsophalangeal Joint in Adults

Congenital dislocation of the fifth metatarsophalangeal (MTP) joint can cause significant limitations in a patient’s ability to wear a closed shoe. Historic treatment has involved amputation of the digit or attempts at reconstruction. These techniques have had limited success with unreliable correction and/or unacceptable cosmesis. The authors present a detailed, methodical approach to reconstruction of this deformity with a stepwise algorithm that addresses both the bony and soft tissue components of the deformity. With this modern technique, reliable and satisfactory results can be expected.

Acute Peroneal Injury

A high clinical suspicion and greater understanding of the anatomy and pathophysiology of lateral ankle injuries have enabled early diagnosis and treatment-improving outcomes of acute peroneal tendon tears. Multiple conditions can be the cause of lateral ankle pain attributed to the peroneal tendons: tenosynovitis, tendinosis, subluxation and dislocation, stenosing tenosynovitis, abnormality related to the os peroneum, as well as tears of the peroneal tendons. It is imperative for the clinician to maintain a high suspicion for peroneal tendon abnormality when evaluating patients with lateral ankle pain.

Role of Total Ankle Arthroplasty in Stiff Ankles

BACKGROUND

The decision tree for the operative treatment of end-stage ankle arthritis involves either ankle arthrodesis (AA) or total ankle arthroplasty (TAA). Although both have documented success providing diminished pain, improved patient-centered outcomes, and improved objective measures of function, arthroplasty is unique in its ability to preserve motion at the tibiotalar joint. Arthroplasty procedures are normally thought of as a motion-sparing surgery rather than a motion-producing procedure, which may limit its success in patients with stiff ankles. Our hypothesis was that there would be improvements in parameters of gait even in patients with a low degree of preoperative total sagittal range of motion.

METHODS

A retrospective review was conducted on patients who underwent total ankle arthroplasty with greater than 1-year follow-up. Seventy-six patients were available who underwent isolated TAA for end-stage ankle arthritis with greater than 1-year follow-up. Patient demographics and preoperative and postoperative gait analyses were evaluated. Using a linear regression model, the effect sizes for the variables of age, gender, BMI, preoperative diagnosis, and preoperative total sagittal range of motion were calculated. Multivariate analysis was used to determine the influence each individual variable had on the many parameters of preoperative gait, postoperative gait, and change in gait after surgery. A post hoc analysis was conducted in which patients were divided into 4 quartiles according to preoperative range of motion. A 1-way analysis of variance (ANOVA) was used to compare improvement in parameters of gait for the 4 subgroups.

RESULTS

Although a greater degree of preoperative sagittal range of motion was predictive of greater postoperative sagittal range of motion, patients with limited preoperative range of motion experienced a greater overall improvement in range of motion, and clinically meaningful absolute improvements in range of motion, and other parameters of gait. The post hoc analysis demonstrated that patients in the lowest quartile of preoperative motion had both statistically and clinically significant greater improvements across numerous parameters of gait, although the absolute values were lower than in the patients with higher preoperative ROM. Age, gender, BMI, and preoperative diagnosis did not correlate with changes in parameters of gait after total ankle arthroplasty.

CONCLUSION

Preoperative range of motion was predictive of overall postoperative gait function. On one hand, a low preoperative range of motion resulted in a lower absolute postoperative function. On the other hand, patients with stiff ankles preoperatively had a statistically and clinically greater improvement in function as measured by multiple parameters of gait. This suggests that total ankle arthroplasty can offer clinically meaningful improvement in gait function and should be considered for patients with end-stage tibiotalar arthritis even in the setting of limited sagittal range of motion.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Radiographic Results and Return to Activity After Sesamoidectomy for Fracture

BACKGROUND

Limited data are available comparing the results of lateral sesamoidectomy and medial sesamoidectomy for the treatment of fractures recalcitrant to nonoperative treatment interventions. The hypothesis of this study was that sesamoidectomy for either lateral or medial sesamoid fractures would not change radiographic alignment of the first ray given the use of identical reconstruction of the plantar plate, intersesamoid ligament, and plantar ligament complex at the time of surgery.

METHODS

This retrospective cohort study compared the outcomes of 46 consecutive patients treated with sesamoidectomy (24 lateral, 22 medial). Patient demographics, mechanisms of injury, and outcomes were recorded. Preoperative, postoperative, and changes in both hallux valgus angle (HVA) and intermetatarsal angle (IMA) were measured.

RESULTS

No statistically significant difference could be detected for age ( P = .577), sex ( P = .134), return to activity ( P = 1.000), likelihood to undergo the procedure again ( P = 1.000), orthotic use postoperatively ( P = 1.000), perioperative complications ( P = .497), duration of symptoms ( P = .711), or length of follow-up ( P = .609). While statistically significant changes in preoperative and postoperative alignment were detected for both medial and lateral sesamoidectomy, these changes were not clinically significant. Patients undergoing medial sesamoidectomy had higher preoperative and postoperative HVA and IMA compared with those undergoing lateral sesamoidectomy. Medial sesamoidectomy patients had a net increase in both HVA and IMA, while patients undergoing lateral sesamoidectomy had a net decrease in both HVA and IMA.

CONCLUSION

Although statistically significant changes in both HVA and IMA were detected, these values were too small to be considered clinically significant. Patient outcomes did not differ between the 2 groups, and sesamoidectomy was used with low patient morbidity for both medial and lateral sesamoid fractures that failed to respond to nonoperative modalities. These data suggest that the underlying mechanics of the foot may be different in patients who sustain medial and lateral sesamoid stress injury, suggesting a possible etiologic difference between medial and lateral sesamoid injuries.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

The Natural History of Charcot Neuroarthropathy

Category:

Diabetes

Introduction/Purpose:

There are limited data in the literature regarding natural history of Charcot Neuroarthropathy (CN) of the foot and ankle. The utility of a classification system should be threefold: accurately describe the disease process, guide the appropriate treatment, and predict the long-term prognosis. This study investigates the natural history of CN of foot and ankle, and whether the Anatomic Classification is predictive of outcome and prognosis.

Methods:

A retrospective review of 334 patients treated at a single institution by a single surgeon from January 1986 to June 2010 was conducted. Clinical records, imaging studies, and operative reports were reviewed to tabulate the Anatomic Classification type, patient demographics (age, gender, BMI, diabetes, RA), number and types of surgeries performed, location of surgery, initial and final job status, ulcer status, ambulatory status and shoe wear type. ANOVA and Pearson Chi square were utilized to assess whether the classification was predictive of variables. P-values of < 0.05 were considered statistically significant.

Results:

Outcomes/p-values are listed in table 1. 35.3% of patients presented with a unilateral Type 1 Charcot foot(n=118), 17.1% presented with a unilateral Type 2(n=57), 13.8% presented with a unilateral Type 3(n=46), and 33.8% presented with bilateral disease(n=113). CN due to RA had increased bilateral involvement(12.4%; 14/113) compared to unilateral involvement(5%,11/221)(p=0.026). Comparing bilateral versus unilateral Types 1,2,or 3, a similar trend was noted(p=0.0939). The Anatomic classification predicted location/need for surgical intervention(p < 0.00001). The classification predicted distal disease was associated with increased likelihood to require shoe-wear modifications(p=0.0001). While a statistically significant difference was not detected, a trend for the classification to predict persistent ulceration at final follow-up was noted. Patients with bilateral involvement and more distal disease were more likely to have ulceration(p=0.0968).

Conclusion:

While the Anatomic classification did not predict ambulatory status, and only trended towards statistical significance for ulceration at the time of final follow-up, there is utility in the classification system for predicting location of surgery as well as shoe-wear at final follow-up. Additionally, patients with CN due to RA had an increased likelihood of having bilateral foot involvement. The Anatomic Classification has clinical utility when counseling patients on the overall course of their disease process.

Male Hallux Valgus Corrected by Translational Osteotomy of First Metatarsal

Category:

Bunion

Introduction/Purpose:

Male hallux valgus (HV) is less common and more severe than in females, and has been reported to be associated with higher Distal Metaphyseal Articular Angle (DMAA). Although valgus-producing osteotomies should increase DMAA, this has not been documented. This study evaluated the results of a translational osteotomy that counter-rotates the distal metatarsal articular surface in a varus direction to re-align the articular surface, and correct the DMAA.

Methods:

Prospectively collected pre-op and post-op data on 26 males with HV were retrospectively reviewed, at a minimum one-year followup. Radiographic data included hallux valgus (HVA), first-second intermetatarsal (IMA) angles, DMAA, medial sesamoid position (MSP), and first MTPJ congruence. Clinical outcomes included Visual Analog Score (VAS), SF-36, and AOFAS forefoot score. MTP range of motion (ROM) was measured. Preoperative radiographic and clinical data were compared to previously published cohort of female patients for the same measures. Paired t-tests compared clinical and radiographic outcomes pre- and postoperatively. Bowker’s Test was used to compare the rate of joint congruence. An alpha of 0.05 was considered significant. Student t-test and Fisher’s Exact Test were for comparison between males and females. Mean age of males with HV was 53.8 (SD=17.7), mean follow-up was 1.68 years.

Results:

Mean radiographic improvement: HVA 36.5º to 15.3º (P=0.0001); IMA 15.9 to 8.1 (P=0.0001); DMAA 13.3º to 6.4º (P=0.0003); MSP 2.8 to 1.2 (P=0.0001); congruence 4/26 to 22/26 (P=0.0001). Mean clinical improvements: VAS 5.7 to 1.0 (P=0.0001); AOFAS 49.6 to 84.7 (P=0.0001); SF36-P 44.7 to 51.2 (P=0.0004). MTP dorsiflexion decreased 58.3º to 51.8º (P=0.0276); plantarflexion 5.8º to 3.0º (P=0.0217). Higher mean preoperative angles in males versus females: HVA 35.8º versus 29º (P=0.0016); IMA 15.9º versus 13.0º, (P=0.0002), MSP 2.7 versus 2.5 (P=0.2012). No difference in DMAA, 13.6 versus 16.4 (P=0.2551). Congruence in males lower (5/27 versus 22/40, P=0.0048). No difference in VAS (5.6 versus 6.3, P=0.1767), AOFAS (50 versus 47.9, P=0.5085), SF-36p (45.1 versus 42.4, P=0.2656), dorsiflexion (57.9º versus 49.4º, P=0.0728), plantarflexion (5.8º versus 4.8º, P=0.7204).

Conclusion:

Prior studies reported the results of mixes of surgical procedures. This is the first large series of adult male HV treated with a single procedure, and the first using this counter-rotational modification of the Scarf osteotomy. The modified Scarf osteotomy combines translation varus counter-rotation to direct the articular surface more medially, explaining decreased DMAA, and with excellent radiographic and clinical outcomes. We demonstrate excellent radiographic and clinical outcomes in a large group of male HV treated with translational osteotomies.

Resection Arthroplasty for Limb Salvage in Severe Unreconstructable Charcot Joints

Category:

Diabetes

Introduction/Purpose:

When non-operative treatment of very severe Charcot neuroarthropathy (CN) of the ankle and hindfoot fails, surgical options for limb salvage are limited. Some patients have insufficient bone stock or medical and psychosocial factors that make arthrodesis untenable. Resection arthroplasty can create a braceable, plantigrade ankle and foot, preserving the limb and maintaining ambulatory independence. This study evaluated the results of resection arthroplasty and bracing as an alternative technique of limb salvage in the subset of patients who would otherwise require amputation for unreconstructable Charcot deformity.

Methods:

The medical records and radiographs of 16 patients who underwent resection arthroplasty for unreconstructable Charcot deformity from 2000-2014 were retrospectively reviewed. All had diabetic peripheral neuropathy. The average follow-up was 46.75 months (range 9-111 months). Data included demographics, medical history, ambulatory status, and soft tissue lesions. Radiographs were categorized according to the Brodsky Charcot classification. Pre-operatively, 2 patients were community ambulators without assistive device. Four patients were wheelchair bound. Ten patients (62.5%) had limited ambulatory independence, as either home ambulators or reliant on assistive devices, such as crutches and walkers. At the time of surgery, 87% had presence of persistent and recalcitrant ulceration as a result of their deformity. Fifteen patients (93%) had Brodsky Type 2 (Hindfoot) or Type 3 (ankle) Charcot joints. Primary outcomes assessed were limb survivorship and ambulatory status at last follow-up. Secondary outcomes included wound complications, infection, and need for subsequent surgical procedures following index procedure.

Results:

Kaplan-Meier survivorship probability estimate for limb salvage at 5 years following resection arthroplasty was 93% (95% CI 66%-99%). A total of 4 resection arthroplasties ultimately failed, requiring BKA. Three out of 4 amputations occurred after 5 years of successful function. Of the 12 patients who retained their limb at final follow-up, all had braceable deformity without evidence of skin breakdown or infection at the time of final follow-up. Eleven of the 12 were independent community ambulators with bivalved AFO (BAFO). With regard to overall changes in ambulatory status following resection arthroplasty, all patients who were independent community ambulators pre-operatively maintained their ambulatory independence post-operatively with use of BAFO. For patients who were either non-ambulatory or dependent ambulators pre-operatively, 10/14 (71%) achieved ambulatory independence.

Conclusion:

Resection arthroplasty with long-term post-operative bracing is an effective alternative technique for limb salvage and preservation of ambulatory independence in the subset of CN patients who would otherwise likely require amputation for unreconstructable deformity.

Functional Parameters of Gait Following Total Ankle Arthroplasty

Category:

Ankle

Introduction/Purpose:

Numerous studies have attempted to study outcomes after total ankle arthroplasty (TAA). The majority of these studies are clinical in nature. There have been some reports that rheumatoid patients have better outcomes after TAA although there are papers that are contradictory. Objective outcome studies of gait after TAA usually measure outcome against a control group or ankle arthrodesis. No studies have attempted to measure objective outcomes of TAA based upon the preoperative diagnosis. Without objectively studying outcomes for patients with osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis, it is unclear whether a difference exists in outcomes after TAA. This study aims to answer the question: Is preoperative diagnosis predictive of outcome after total ankle arthroplasty?

Methods:

A retrospective review of 75 patients who underwent isolated TAA with a minimum one-year follow-up, including patient demographics, pre-operative diagnosis, and pre and postoperative gait studies was conducted. Gait function was evaluated for postoperative improvement using multivariate analysis to determine the influence of patient variables on parameters of gait. ANOVA was conducted to compare improvement in gait based on preoperative diagnosis. P-values of < 0.05 were considered statisticallysignificant.

Results:

Outcomes/p-values are listed in table 1. While not reaching statistical significance, a meaningful clinically important difference was seen across numerous parameters. Temporal Spatial Parameters Patients with RA had the slowest preoperative cadence the fastest postoperative cadence. They also had the greatest improvement in walking speed. Patients with osteoarthritis had the greatest increase in walking speed. KinematicParameters Patients with RA had the greatest improvement in maximum plantarflexion and the least improvement in maximum dorsiflexion. Patients with osteoarthritis had the least improvement in maximum plantarflexion and the most improvement in mean maximum dorsiflexion. Patients with osteoarthritis had the greatest improvement in total ROM. Kinetic Parameters Patients with RA had the greatest improvement in peak ankle power while patients with osteoarthritis had the greatest post-operative power.

Conclusion:

There is a lack of data supporting the optimal candidate for TAA. While statistical significance was not reached across a number of the parameters of gait analysis, a number approached statistical significance. Given the relatively small sample size, it is possible that a larger cohort would reach statistical significance. Patients with osteoarthritis generally had superior preoperative and postoperative parameters of gait while patients with RA had the greatest improvement in parameters of gait. Patients with post-traumatic arthritis consistently had less improvement than patients with either osteoarthritis or RA.

Early radiographic and clinical results of Salto total ankle arthroplasty as a fixed-bearing device

BACKGROUND

Total ankle replacement has increased in popularity in the management of severe tibiotalar arthritis. Most previous clinical reports focused on mobile-bearing designs. This study evaluates early radiographic and clinical results of the Salto fixed bearing design.

METHODS

Twenty-three Salto fixed-bearing implants were prospectively studied. Records were reviewed for clinical outcome scores (VAS, AOFAS, SF36), subsequent surgeries, complications, radiographic data and implant survivorship. Average follow-up was 36 months.

RESULTS

Statistically significant improvements in VAS, AOFAS ankle/hindfoot scores, and SF36 scores were shown at an average of 3 years postoperatively. At 3 years followup, survivorship of the implant was 82.6% with any reoperation as the endpoint and 95.6% for revision or removal of components. Seven patients had radiolucencies around the implant, one of which required revision to arthrodesis.

CONCLUSION

The fixed-bearing Salto ankle replacement has comparable early radiographic and clinical results to reports of the mobile-bearing Salto of comparable followup.

LEVEL OF EVIDENCE

Level IV.

Joint salvage after neglected intra-articular physeal fracture of the hallux in high-level gymnasts

Chronic sports-related injuries involving the hallux are well known in adult populations. However, they are less frequently described in adolescents. We present 2 cases of elite-level gymnasts with neglected Salter-Harris IV fractures involving the proximal phalanx of the great toe following a severe hyperextension injury to the metatarsophalangeal joint. Both were successfully treated with open reduction and internal fixation with return to pre-injury level of activity, improvement in outcome scores, and demonstration of no disability from injury 2 years after surgical intervention.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case Series.

Salvage of avascular necrosis of the talus by combined ankle and hindfoot arthrodesis without structural bone graft

BACKGROUND

Osteonecrosis of the talus is a well-recognized pathology, which can result in significant hindfoot collapse resulting in poor function and pain. Treatment with intramedullary tibiotalocalcaneal arthrodesis (IMTCA) using a retrograde intramedullary nail is widely utilized for severe concomitant tibiotalar and subtalar pathologies. This study reports the results of ankle and hindfoot arthrodesis in patients with arthritis and deformity caused specifically by talar osteonecrosis.

METHODS

Fourteen ankle and hindfoot arthrodeses with retrograde intramedullary nail were studied, with a mean follow-up of 26 months. Medical records were reviewed for operative technique, concomitant procedures, bone graft used, and postoperative complications including nonunion, infection, nerve injury, wound healing issues, and the need for additional surgeries. Clinical outcomes included Visual Analogue Scale for pain, the AOFAS Ankle/Hindfoot Score, and the SF-36 questionnaire.

RESULTS

Over 80% of cases had osteonecrosis involving the entire body of the talus. In 4 cases tibiocalcaneal arthrodesis was performed, with the remaining talar head-neck portion fused to anterior aspect of tibia. Union was achieved in all cases. The mean preoperative VAS score was 6.9 (range 5 to 9, SD ± 1.5) decreasing to 1.7 (range 0 to 6, SD ± 2.2) postoperatively (P = .00008). The mean preoperative AOFAS score was 32.7 (range 20 to 46, SD ± 8.7), increasing to 72.1 (range 46 to 86, SD ± 10.1, P = .00003). The mean preoperative SF-36 physical component score was 30.5 (range 21 to 42, SD ± 6.9) increasing to 42.8 (range 20 to 60, SD ± 11.4) postoperatively (P = .02). Complications included 1 stress fracture, 4 hardware removals, and 1 superficial infection.

CONCLUSION

Ankle and hindfoot arthrosis due to extensive talar AVN can be successfully treated with IMTCA.

Improvement in gait following combined ankle and subtalar arthrodesis

BACKGROUND

This study assessed the hypothesis that arthrodesis of both the ankle and the hindfoot joints produces an objective improvement of function as measured by gait analysis of patients with severe ankle and hindfoot arthritis.

METHODS

Twenty-one patients with severe ankle and hindfoot arthritis who underwent unilateral tibiotalocalcaneal arthrodesis with an intramedullary nail were prospectively studied with three-dimensional (3D) gait analysis at a minimum of one year postoperatively. The mean age at the time of the operation was fifty-nine years, and the mean duration of follow-up was seventeen months (range, twelve to thirty-one months). Temporospatial measurements included cadence, step length, walking velocity, and total support time. The kinematic parameters were sagittal plane motion of the ankle, knee, and hip. The kinetic parameters were sagittal plane ankle power and moment and hip power. Symmetry of gait was analyzed by comparing the step lengths on the affected and unaffected sides.

RESULTS

There was significant improvement in multiple parameters of postoperative gait as compared with the patients' own preoperative function. Temporospatial data showed significant increases in cadence (p = 0.03) and walking speed (p = 0.001) and decreased total support time (p = 0.02). Kinematic results showed that sagittal plane ankle motion had decreased, from 13.2° preoperatively to 10.2° postoperatively, in the operatively treated limb (p = 0.02), and increased from 22.2° to 24.1° (p = 0.01) in the contralateral limb. Hip motion on the affected side increased from 39° to 43° (p = 0.007), and knee motion increased from 56° to 60° (p = 0.054). Kinetic results showed significant increases in ankle moment (p < 0.0001) of the operatively treated limb, ankle power of the contralateral limb (p = 0.009), and hip power on the affected side (p = 0.005) postoperatively. There was a significant improvement in gait symmetry (p = 0.01).

CONCLUSIONS

There was a small loss of sagittal plane motion in the affected limb postoperatively. There were marked increases in gait velocity, ankle moment, and hip motion and power, documenting objective improvements in ambulatory function. The data showed that preoperative ankle motion was greatly diminished. This may suggest that pain is more important than stiffness in asymmetric gait.