Liposomal Bupivacaine Versus Continuous Popliteal Sciatic Nerve Block in Total Ankle Arthroplasty

BACKGROUND

Liposomal bupivacaine (LB) is widely used in joint arthroplasty, but there is little reported on the use of LB in foot and ankle surgery. Continuous popliteal sciatic nerve block (CPSNB) is more commonly used for major foot and ankle reconstructions. The purpose of this study was to compare use of intraoperative LB injection to CPSNB as a regional anesthetic for total ankle arthroplasty (TAA), with attention to postoperative pain scores, narcotic use, and complications.

METHODS

Retrospective review of TAA patients of 2 fellowship-trained orthopedic foot and ankle surgeons was performed. Patients received either preoperative single-shot popliteal sciatic nerve block with 0.2% ropivacaine followed by intraoperative injection of LB or preoperative CPSNB alone. Outcomes examined were visual analog scale (VAS) pain score at 8 hours, 24 hours, 1 week, and 3 weeks following surgery; need for opioid pain medication refill; physician office notification for pain issues or other adverse events; and complications within the first 90 days following surgery. Standard statistical analysis was performed, and P < .05 was considered significant. Seventy-five patients were identified who underwent TAA and met inclusion criteria. Forty-one received LB, and 34 received CPSNB.

RESULTS

No statistical difference was seen between groups with regard to complications, emergency department visits, readmissions, reoperations, VAS pain score at any time point, physician office contacts, and narcotic refills. Sixteen of 41 (39%) LB patients had narcotic refills, versus 12 of 34 (35%) CPSNB patients ( P = .81). Two of 41 (5%) LB patients had a complication postoperatively, versus 4 of 34 (12%) CPSNB patients. There were no complications specific to the anesthetic used in either group.

CONCLUSION

This is the first study evaluating the use of LB for total ankle arthroplasty. Liposomal bupivacaine was safe and effective as an option for regional anesthetic and postoperative pain control, with comparable results to CPSNB.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Treatment of postaxial polydactyly with plantar plate and medial collateral ligament reconstruction after supernumerary excision: A case report

Introduction:

Polydactyly is the most common congenital foot anomaly and consists of partial or complete duplication of a toe. Traditionally, surgical treatment has been amputation. There is little evidence when surgical treatment requires repairing the stabilizing structures of the metatarsophalangeal joint

Objective:

Assess the functional and radiologic outcomes of a case of postaxial polydactyly requiring plantar plate plate and medial collateral ligament reconstruction.

Methods:

A 59-year-old female presented at clinic complaining from bilateral fifth toe polydactyly and metatarsalgia. A rudimentary extra toe with bony structures poorly developed was observed in the left foot. An excision was performed on the left foot. In the right foot, a fully developed extra digit was observed with medial and downwards deviation underneath the fourth metatarsal.

Results:

Medial fifth-toe excision, plantar plate repair and medial collateral ligament reconstruction were performed due to malformation and widening of the distal surface of the plantar plate. Patient satisfaction and adequate functional status were observed at one-year follow-up.

Conclusion:

The plantar plate is the principal stabilizer of the MTP joint; therefore its reconstruction is of paramount importance for forefoot biomechanics.

Safety of Outpatient Total Ankle Arthroplasty vs Traditional Inpatient Admission or Overnight Observation

BACKGROUND

Total joint surgeons have successfully performed hip, knee, and shoulder arthroplasty procedures in the outpatient setting without compromising safety, satisfaction, or results. The purpose of this study was to evaluate outpatient total ankle arthroplasty (TAA) as compared with overnight or extended inpatient stay, with regard to 90-day medical and operative complications, reoperations, readmissions or emergency room visits, and pain control.

METHODS

The medical records of patients who underwent TAA with 1 fellowship-trained orthopedic foot and ankle surgeon were reviewed. Outcome measures included operative complications, adverse medical events, readmission or emergency room visit for any reason, or reoperation within 90 days following surgery; surgeon's office contact before first postoperative visit regarding pain or other issues; visual analog scale pain score at the first postoperative visit; and need for narcotic refill. Outcomes were assessed by admission status: outpatient, overnight observation, or inpatient admission. Standard statistical analysis was used, and P < .05 was considered significant.

RESULTS

Eighty-one patients underwent TAA who met inclusion criteria, and 8 had a complication (10%). A significant difference in complication rate was seen among groups ( P = .01) but not rate of readmission or reoperation. Of 16 patients, 5 (31%) who were admitted for 2 or more nights following surgery had a complication, as opposed to 3 of 65 (5%) who were outpatient or admitted overnight ( P = .01). There were no differences in frequency of postoperative phone calls, narcotic refills, or visual analog scale pain scores at the first postoperative visit. There were no adverse medical events.

CONCLUSION

With proper instruction, TAA was performed safely in the outpatient setting. As health care policy continues to evolve in the United States, safe and efficient practices will remain a priority.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Soft Tissue Reconstruction After Total Ankle Arthroplasty

Wound complications following total ankle replacement are common. A team approach, including plastic surgeons, should be utilized to manage these wound issues. The handling of the wound, from the index procedure, to a variety of flaps, can be utilized to provide a successful outcome following an ankle replacement.

Measurement of Nitinol Recovery Distance Using Pseudoelastic Intramedullary Nails for Tibiotalocalcaneal Arthrodesis

BACKGROUND

Tibiotalocalcaneal arthrodesis is a salvage procedure for patients with complex disease of the ankle and subtalar joints. Despite the clinical efficacy and mechanical advantage of intramedullary nails, complications, such as nonunion, are common. It may be possible to sustain compression in the face of bone resorption and implant loosening over the course of healing using a novel pseudoelastic intramedullary nail with an internal nitinol element.

METHODS

We identified 15 patients with average age of 54.7 years (range, 28-75 years) who had undergone a tibiotalocalcaneal arthrodesis using a pseudoelastic intramedullary nail. Serial radiographs were used to determine the amount and rate of nitinol element migration over the first 3 postoperative months.

RESULTS

Postoperatively, there was at least 2.38 mm of nitinol element migration proximally with mean of 5.58 mm (± 1.38), (range, 2.38-8.11 mm). Average follow-up time was 195 days (± 106.3), (range, 89-490 days). On average, 86% of the total recovered distance took place within the first 39.7 days (±10.03).

CONCLUSIONS

The nitinol element recovers distance when stretched intraoperatively and maintains moderate compression in response to bone resorption. Further studies are needed to assess if this increased compression lends itself to higher fusion rates than traditional intramedullary nails.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case series.

The Use of a Cellular Bone Allograft Containing Multipotent Adult Progenitor Cells for Foot and Ankle Arthrodeses

Category:

Basic Sciences/Biologics

Introduction/Purpose:

Arthrodesis procedures are commonplace in foot and ankle surgery. Unfortunately, nonunion rates have been reported to be as high as 40%. To combat nonunion, autograft bone is often used but has been associated with morbidity and poor cell quality. Therefore, the use of cellular bone allograft (CBA) has become commonplace. Traditional CBAs are osteoconductive, osteoinductive and the cellular component is typically osteogenic but not angiogenic. The added property of angiogenesis may be beneficial in achieving fusion. The purpose of this study was to determine the efficacy of a CBA composed of MAPC-class cells that have both osteogenic and angiogenic properties.

Methods:

The CBA (map3, RTI Surgical, Alachua, FL) was used in 41 distinct foot and ankle arthrodesis sites in 37 consecutive patients with a mean age of 52 years (range, 19-88). In all cases the graft was interposed between the prepared bone surfaces prior to hardware placement. All patients were followed until fusion occurred or a revision procedure was performed in cases of nonunion. Successful fusion required >50% osseous bridging on CT scan and the presence of bridging bone without signs of nonunion on plain radiographs. Additionally, successful fusion required resolution of preoperative symptoms and maintenance of fixation across all treated joints.

Results:

Overall, fusion was achieved in 88% (36/41) arthrodesis sites. There were 11 patients/sites of previous nonunion. In these revision cases, the fusion rate was 82% (9/11). There were no complications attributed to the use of map3.

Conclusion:

Fusion rates using map3 were higher than or comparable to fusion rates with autograft that have been reported in the recent literature. Map3 was a safe and effective graft material to achieve fusion and may provide an effective autograft replacement for foot and/or ankle arthrodeses.

Management of Osteochondral Lesions of the Talus Using Autologous Chondrocyte Implantation

Category:

Arthroscopy

Introduction/Purpose:

Osteochondral lesions of the talus (OLT) are frequent occurrences when patients sustain both traumatic and atraumatic ankle injuries with a report rate of up to 70% OLT in patients who sustain an ankle sprain or fracture. Surgical treatment options for OLT is either reparative or replacement and are dictated by characteristics of the lesion, including size and presence or absence of cysts. Periosteal-autologous chondrocyte implantation (P-ACI) or MACI (matrix-induced autologous chondrocyte implantation) is useful for lesions with or without cysts under 2.5cm2. We hypothesize that MACI will have the lowest reoperation rate and highest patient satisfaction rate in treating OLT.

Methods:

A systematic review was registered with PROSPERO and performed with PRISMA guidelines using three publicly available free databases. Therapeutic clinical outcome investigations reporting OLT outcomes with levels of evidence I-IV were eligible for inclusion. All study, subject, and surgical technique demographics were analyzed and compared between continents and countries. Statistics were calculated using Student’s t-tests, one-way ANOVA, chi-squared, and two-proportion Z-tests.

Results:

Nineteen articles met our inclusion criteria, which resulted in a total of 343 patients. Six studies pertained to arthroscopic MACI, 8 to open MACI, and 5 studies to open PACI. All studies were Level IV evidence. Due to study quality, imprecise and sparse data, and potential for reporting bias, the quality of evidence is low. In comparison of open and arthroscopic MACI, we found both advantages favoring open MACI (AOFAS and MOCART score). However, open MACI had higher complication rates versus arthroscopic (18.18% vs 0.78%, p = 0.002). In addition, the rate of impingement was noted to be significantly higher for the open technique of MACI with a rate of 10.61% as opposed to 0.78% for the arthroscopic technique (p = 0.01).

Conclusion:

No procedure demonstrates superiority or inferiority between the combination of open or arthroscopic MACI and PACI in the management of OLT less than 2.5 cm2. Ultimately well-designed randomized trials are needed to address the limitation of the available literature and further our understanding of the optimal treatment options.

Reduced Bacterial Growth on Titanium Screws With Nanophase TiO2 Surface Treatment

Category:

Other

Introduction/Purpose:

An important strategy in the reduction of orthopedic infections is to develop implant materials that prevent initial bacteria adhesion and growth onto implant surfaces. Bacterial localization and biofilm formation may lead to acute and chronic infections[1]. Biofilm formation on implant surfaces protects bacteria from the immune system and antibiotic therapy, thus, requiring an aggressive treatment of antibiotics that frequently do not work post biofilm formation[2]. Thus, to prevent implant infections, various strategies have been developed aside from conventional systemic and local antibiotic treatment. Recently, there has been increasing interest for coating implants with other materials to improve osseointegration and prevent infection, chronic inflammation, and unwanted foreign body responses[3]. The current study focuses on modifying the surface of titanium implants by treating them with nanophase titanium dioxide using electrophoretic deposition.

Methods:

Nanophase titanium dioxide was synthesized using a wet chemical synthesis and was deposited on Ti-6Al-4 V titanium screws using a cathodic arc deposition plasma system. Bacterial assays were conducted using Staphylococcus aureus (ATCC® 29740™), Pseudomonas aeruginosa (ATCC® 39324™) and an ampicillin resistant strain of E. coli (BIO-RAD Strain HB101 K-12 #166-0408 and pGLO Plasmid #166-0405). 0.03% tryptic soy broth (TSB) (Sigma Aldrich, Cat # 22092) and agar (Sigma-Aldrich, Cat # A1296) were used as the media and colony forming assays were performed to determine bacterial adhesion.

Results:

Nanophase titanium dioxide was successfully synthesized and applied onto the desired surface. A statistically significant decrease in bacterial adhesion was observed across all 3 strains of bacteria; an example of confocal images for S. Aureus is given in figure 1. In addition, decreased macrophage functions and increase osteoblast functions were also observed in the nano TiO2 treated Ti6Al4 V screws. Importantly, this was all achieved without the use of drugs and/or antibiotics decreasing the chance for the spread of antibiotic resistant bacteria and drug side effects.

Conclusion:

The screws were successfully coated using EPD and reduced bacterial adhesion on the coated surface was observed.

Fluid Dynamics Play a Role In Distributing Ankle Stresses in Anatomic and Injured States

Category:

Basic Sciences/Biologics

Introduction/Purpose:

In 1976, Ramsey and Hamilton published a landmark cadaveric study demonstrating a dramatic 42% decrease in tibiotalar contact area with only 1 mm of lateral talar shift. An increase in principal stress of at least 72% is predicted based on these findings though the delayed development of arthritis in minimally misaligned ankles does not appear to be commensurate with the results found in dry cadaveric models. We hypothesize that synovial fluid is a previously unrecognized factor that contributes significantly to stress distribution in the tibiotalar joint in anatomic and injured states.

Methods:

As it is not possible to directly measure contact stresses with and without fluid in a cadaveric model, finite element analysis (FEA) was employed for this study. FEA is a modeling technique used to calculate stresses in complex geometric structures by dividing them into small, simple components called elements. Four test groups were investigated utilizing a finite element model (FEM): baseline ankle alignment, 1 mm laterally translated talus and fibula, and the previous two bone orientations with fluid added. The FEM selected for this study was the Global Human Body Models Consortium (GHBMC) M50 version 4.2, a validated model of an average sized male. The ankle was loaded at the proximal tibia with a distributed load equal to the GHBMC body weight and first principal stress (which is also the maximum principal stress) was computed.

Results:

All simulations were stable and completed with no errors. In the baseline anatomic configuration, the addition of fluid between the tibia, fibula and talus reduced the maximum principal stress measured in the distal tibia at maximum load from 31.3 N/mm2 to 11.5 N/mm2. Following 1 mm lateral translation of the talus and fibula there was a modest 30% increase in the maximum stress in fluid cases. Qualitatively, translation created less high stress locations on the tibial plafond when fluid was incorporated in the model (Figure 1).

Conclusion:

The findings in this study demonstrate a potential role for synovial fluid in distributing stresses within the ankle that has not been considered in historical dry cadaveric studies. The increase in maximum stress predicted by simulation of an ankle with fluid is less than half that projected by cadaveric data, indicating a protective effect of fluid in the injured state. The trends demonstrated by these simulations suggest that bony alignment and fluid in the ankle joint change loading patterns on the distal tibia and should be accounted for in future experiments.

Measurement of Nitinol Recovery Distance Using Pseudoelastic Intramedullary Nail in Tibiotalocalcaneal Arthrodesis

Category:

Ankle

Introduction/Purpose:

Tibiotalocalcaneal(TTC) arthrodesis is a salvage procedure for patients with complex disease of the ankle and subtalar joints. Despite the clinical efficacy and mechanical advantage of intramedullary nails, complications, such as nonunion, are not uncommon. It may be possible to sustain compression in the face of bone resorption and implant loosening over the course of healing using a novel pseudoelastic intramedullary nail.

Methods:

We identified 15 patients (age+54.7+/-20.0 years) who had undergone a tibiotalocalcaneal arthrodesis using a pseudoelastic intramedullary nai. Serial radiographs were used to determine the amount and rate of Nitinol element migration over time.

Results:

Three months after surgery, there was at least 2.38mm of Nitinol element migration proximally with mean of 5.58mm(range: 2.38 to 8.11mm). Average follow up time was 195 days (range: 89 to 490 days).

Conclusion:

The Nitinol element recovers distance when stretched intra-operatively and maintains moderate compression in response to bone resorption. Further studies are needed to assess if this increased compression lends itself to higher fusion rates than traditional IMN’s.

Technique Tip: The Use of Cannulated Drill as a Tamp to Remove Loose Cannulated Screws

Subtalar arthrodesis is considered to be the gold standard surgical solution for end-stage subtalar joint arthrosis. Although subtalar joint fusion rates are high, nonunion has been reported to range from 0% to 43%. Revision subtalar arthrodesis regardless of etiology often requires removal of loose hardware in soft bone. The inability of screw threads to engage bone may result in longer operative time, frustration for the surgeon, and potential negative outcome for the patient. We describe a novel technique in which a cannulated drill bit is used as a tamp to remove subtalar arthrodesis screws. We have found this method to be efficient and safe and transferable to any extremity.

LEVELS OF EVIDENCE

Therapeutic, Level V: Expert opinion.

Effect of Facility on the Operative Costs of Total Ankle Arthroplasty

Category:

Ankle Arthritis

Introduction/Purpose:

Cost containment is increasingly important in health care. Currently, Medicare does not reimburse for total ankle replacement (TAR) in the outpatient, ambulatory setting. Therefore, TAR in Medicare patients must be performed in the inpatient setting. The purpose of this study was to investigate if ambulatory surgery centers (ASC) can deliver lower-cost care and to identify sources of those cost savings in total ankle replacement (TAR). We hypothesize that total ankle arthroplasties cost significantly less than when performed in an inpatient setting.

Methods:

We performed a cost identification analysis of primary TAR at a single academic medical center. Multiple costs and time measures were taken from 574 consecutive patients over 4 years at either an inpatient facility or ASC. The relationships between total cost and operative time and multiple variables, including patient age, gender, comorbidities, type of implant used, and concurrent procedures performed were examined, using multivariate analysis and regression modeling to identify cost drivers or explanatory variables.

Results:

The mean operative cost over 4 years was significantly greater at the inpatient facility ($50,460) than at the outpatient facility ($46,283) (p < 0.0001, CI $3,752-$4,685). Significant cost drivers of this difference were in-patient ($1,759), physical/occupational therapy ($346), pharmacy ($233), and operating room costs ($2,752). If we were to perform all total ankle replacements in the four-year period at the ASC, the hospital system would have saved $1,445,242.00.

Conclusion:

The most significant predictor of cost was facility type. This study supports the use of ASC facilities to achieve efficient resource utilization in the operative treatment of total ankle arthroplasties. We also identified several specific costs and time measurements that can serve as potential targets to improve utilization.

Hallux Varus: An Underreported Presentation of Rheumatoid Arthritis

The prevalence of hallux varus deformity in rheumatoid arthritis (RA) has been reported to be extremely rare. However, in South Asian Countries, where open-toed shoes are habitual footwear for the majority of people, we have found that hallux varus is a common deformity in patients with RA. This rate of occurrence is much more common than that in published hallux deformities in RA and reinforces the impact of footwear on the development of hallux deformities. In this report, we present 3 illustrative cases of hallux varus developed in patients with RA and review the etiology of hallux varus deformity.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case Study.

Use of a Continuous External Tissue Expander in Total Ankle Arthroplasty: A Novel Augment to Wound Closure

Despite major improvements in surgical technique and implant designs in total ankle arthroplasty (TAA), wound healing complications are still commonly encountered. Not only do these problems delay postoperative recovery and threaten functional outcomes, they also carry an increased risk of progression to deep wound infection, which can jeopardize ultimate retention of the implant. In an effort to reduce the high frequency of wound-related complications after TAA, we have incorporated the use of continuous external tissue expansion (CETE) to augment our closures of the anterior ankle incision. CETE is an innovative technique that is currently being used to aid in the rapid closure of acute and chronic full thickness soft tissue defects, including fasciotomy wounds, high grade open fractures, and chronic foot ulcers. By exploiting the viscoelastic properties of the skin, this technique not only facilitates wound edge approximation of full thickness defects, it also helps take tension off tenuous incisions, thus allowing them to heal and reducing the chance for wound dehiscence. This is the first description of the use of an external tissue expander for the prevention of wound healing complications in the setting of TAA. Since introducing CETE to the closure of our TAA incisions, we have seen a decrease in the number of postoperative wound complications and time to wound healing. Based on our experience, we believe that the use of CETE for the prophylactic management of tenuous surgical incisions, specifically those used in the anterior approach to the ankle during TAA, is both safe and efficacious.

LEVELS OF EVIDENCE

Level V: Technique tip.

Novel Technique for Treatment of Calcaneal Tuberosity Fractures

Calcaneal tuberosity fractures comprise only 1% to 2% of all calcaneal fractures. Treatment of these injuries has traditionally included open reduction and internal fixation with various means including lag screws, suture anchors, and K-wires. This article reports on a series of cases treated with excision of the tuberosity fragment with repair of the Achilles tendon supplemented by a flexor hallucis longus tendon transfer.

Dual plating with bone block arthrodesis of the first metatarsophalangeal joint: A clinical retrospective review

BACKGROUND

First metatarsal phalangeal joint (MTP) arthrodesis is challenging in the setting of bone loss. The purpose of this study was to describe the results of interpositional grafting and arthrodesis of the first MTP joint using two plates in a 90/90 configuration.

MATERIALS AND METHODS

Eleven patients had an MTP arthrodesis with 90-90 plating with an interpositional allograft. We analyzed the fusion rate, restoration of first ray length, patient satisfaction, and complication rates.

RESULTS

The overall union rate was 90.9%, with an average restoration of 11 ± 4.5mm in length to the first ray. The average time to fusion was 10.7 ± 1 weeks. The mean preoperative AOFAS score improved significantly. The complication rate was 18.2% and included one superficial wound infection and one non-union who underwent a successful fusion after revision.

CONCLUSION

Arthrodesis of the first MTP joint with two 90/90 plates and restoration of length using an interpositional graft has excellent patient satisfaction and functional outcomes.

A Short-Term Retrospective of First Metatarsophalangeal Joint Arthrodesis Using a Plate With PocketLock Fixation

BACKGROUND

Various techniques have been described for arthrodesis of the first metatarsophalangeal (MTP) joint. The purpose of this study was to retrospectively review the results of fixation for the first MTP arthrodesis of patients treated using dome-shaped reamers to prepare the joint surfaces and a novel MTP Plate with PocketLock fixation.

METHODS

Between July 2012 and November 2013, 16 feet in 16 patients were treated with a first MTP arthrodesis with a MTP Plate with PocketLock fixation. The mean patient age was 58.8 years (range, 46-82 years). Physical and radiographic examinations were performed at follow-up visits. The average follow-up period was 17.3 months. The radiographs were examined for union (3 bridging cortices), time to union, hardware failure, or other radiographic complications. The charts were reviewed to assess AOFAS-MTP-IP (American Orthopaedic Foot & Ankle Society metatarsophalangeal-interphalangeal) scores and postoperative complications.

RESULTS

Fusion was seen in 11 of 16 feet (68.8%) and partial union in 1 patient (6.3%). Five nonunions (31.2%) were noted in the sample group: All were symptomatic and required revision surgery. No malunions were identified in our sample. One hardware failure was documented in a nonunion patient. The mean time to osseous union was 81.7 ± 15.9 days. The preoperative AOFAS MTP-IP score was 55.6 and the postoperative score was 64.7.

CONCLUSION

The high nonunion and revision surgery rates demonstrate that this particular plate should be used with caution for a first MTP joint arthrodesis.

LEVEL OF EVIDENCE

Therapeutic, Level IV: Case series.

Midtarsal Reconstructive Arthrodesis Using a Multi-Axial Correction Fixator in Charcot Midfoot Arthropathy

Reconstructive surgeries for Charcot foot are challenging due to complicated conditions and comorbidities including poor bone quality, sensory abnormalities, poor vascularity, and immunity impairment. Although various fixation devices, including screws, plates, and external fixators, have been used in the surgical reconstruction of the Charcot midfoot, all of these devices are associated with some disadvantages. This study aims to evaluate the outcome of the Multi-Axial Correction (MAC) monolateral external fixation system for the reconstructive surgery of midfoot Charcot neuroarthropathy. A total of 11 feet with midfoot Charcot arthropathy were treated surgically using the MAC fixation system solely or accompanied with minimal internal fixation. The mean postoperative follow-up was 29 (range = 12-44) months. The mean postoperative timing of the MAC system removal was 8.7 (range = 5-14) weeks. No pin tract infections were observed. All patients went on to successful union and correction of a rocker bottom deformity. No cases resulted in limb amputation. All patients were able to ambulate with custom diabetic shoes and insoles in 9 patients (10 feet) and commercially available shoes in 1 patient (1 foot). This study suggests that the MAC system can be an acceptable, easy option for the surgical treatment of midfoot Charcot arthropathy.

LEVEL OF EVIDENCE

Therapeutic, Level IV: Case series.

Allograft Reconstruction of Chronic Tibialis Anterior Tendon Ruptures

BACKGROUND

Chronic ruptures of the tibialis anterior tendon are often associated with tendon retraction and poor-quality tissue, resulting in large segmental defects that make end-to-end repair impossible. Interpositional allograft reconstruction has previously been described as an operative option in these cases; however, there are no reports of the clinical outcomes of this technique in the literature.

METHODS

Eleven patients with chronic tibialis anterior tendon ruptures underwent intercalary allograft recon-struction between 2006 and 2013. Patient demographics, injury presentation, and details of surgery were reviewed. Postoperative outcomes at a mean follow-up of 43.8 (range, 6-105) months included the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score, Short Form-12 (SF-12) physical health score, Lower Extremity Functional Score (LEFS), visual analog scale (VAS) pain rating, dorsiflexion strength, gait analysis, and complications.

RESULTS

The average postoperative dorsiflexion strength, as categorized by the Medical Council grading scale, was 4.8 ± 0.45. The average postoperative VAS score was 0.8 ± 1.1. The average LEFS was 66.9 ± 17.2, SF-12 physical health score was 40.1 ± 14.4, and AOFAS score was 84.3 ± 7.7. One complication occurred, consisting of transient neuritic pain in the superficial peroneal nerve distribution. There were no postoperative infections, tendon reruptures, reoperations, or allograft-associated complications.

CONCLUSION

Allograft reconstruction of chronic irreparable tibialis anterior tendon ruptures yielded satisfactory strength, pain, and patient-reported functional outcomes. This technique offers a safe and reliable alternative, without the donor site morbidity associated with tendon transfer or autograft harvest.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Clinical Presentation and Management of Hallux Rigidus

Hallux rigidus is the most commonly occurring arthritic condition of the foot and is marked by pain, limited motion in the sagittal plane of the first metatarsophalangeal joint and varying degrees of functional impairment. In conjunction with clinical findings, radiographic grading helps guide therapeutic choices. Nonsurgical management with anti-inflammatory medications, corticosteroid injections, or shoewear and activity modifications can be successful in appropriately selected patients. Patients with more severe disease or refractory to conservative management may benefit from surgical intervention. Operative options range from joint-preserving procedures (eg, cheilectomy with or without associated osteotomies) to joint-altering procedures (eg, arthroplasty or arthrodesis).

Lessons Learned From Google Glass

Importance. Wearable devices such as Google Glass could potentially be used in the health care setting to expand access and improve quality of care. Objective. This study aims to assess the demographics of Google Glass users in health care and determine the obstacles to using Google Glass by surveying those who are known to use the device. Design. A 48-question survey was designed to assess demographics of users, technological limitations of Google Glass, and obstacles to implementation of the device. Setting. The physicians surveyed worked in various fields of health care, with 50% of the respondents being surgeons. Participants. Potential participants were found using an Internet search for physicians using Google Glass in their practice. Main Outcome Measures. Outcome measures were divided into demographic information of users, technological limitations of the device, and administrative obstacles. Results. A 43.6% response rate was observed. The majority of users were male, assistant professors, in academic hospitals, and in the United States. Numerous technological limitations were observed by the majority, including device ergonomics, display location, video quality, and audio quality. Patient confidentiality and data security were the major concerns among administrative obstacles. Conclusions and Relevance. Despite the potential of Google Glass, numerous obstacles exist that limit its use in health care. While Google Glass has been discontinued, the results of this study may be used to guide future designs of wearable devices.