Plantar Plating for Medial Naviculocuneiform Arthrodesis in Progressive Collapsing Foot Deformity

Background:

Medial column procedures are commonly used to treat progressive collapsing foot deformity (PCFD) reconstruction. The aim of this research is to present the clinical results of plantar plating for medial naviculocuneiform (NC) arthrodesis when NC joint pathology contributes to medial arch collapse. The authors hypothesized that lag screws with a plantar neutralization plate would result in a satisfactory NC joint fusion rate.

Methods:

A single-surgeon, retrospective case series was performed on patients with flexible PCFD who underwent NC arthrodesis using lag screws and a contoured neutralization plate applied plantarly across the medial NC joint as part of PCFD reconstruction. Thirteen patients (11 females, 2 males; mean age 53.1 [34-62] years) between 2016 and 2019 were identified for inclusion. Mean follow-up was 25.2 ± 12.7 months. Preoperative and postoperative anteroposterior talo–first metatarsal angle, lateral talo–first metatarsal angle, talonavicular coverage angle, and calcaneal pitch were measured. Union was evaluated radiologically. AOFAS midfoot scores were recorded at final follow-up.

Results:

All parameters demonstrated a significant improvement. Fusion was confirmed in 11 of 13 patients (85%) at a mean 5.7 ± 2.1 months. One patient required a revision of their NC fusion because of symptomatic nonunion. There were no cases of symptomatic plantar hardware.

Conclusion:

The results of this small cohort series suggest that lag screw with plantar plate NC arthrodesis yielded generally improved short-term radiographic and clinical outcomes in PCFD patients with medial arch collapse through the NC joint.

Level of Evidence: Level IV, retrospective case series.

Acute subdural hematoma in an elite-level rugby union player

Acute subdural hematoma is a rare but potentially fatal medical condition in athletes. This condition has been reported in both contact and non-contact sports. Patients who survive an acute subdural hematoma typically have lifelong deficits and require extensive rehabilitation. Prompt recognition of this condition and access to a hospital with an available neurosurgeon is critical. To our knowledge, this is the first report of a subdural hematoma in an elite-level rugby player.

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Prompt recognition of head injuries is vital to prevent devastating outcomes.

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History and subjective symptoms should be carefully assessed after a head injury.

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Medical staff should remain vigilant, symptoms may develop over days or weeks.

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Expedient transport to a facility with neurosurgical support should be available.

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Transport should be considered, even in the absence of concerning exam findings.

Don't Lose Your Nerve: Evaluation and Management of Neurogenic Pain in the Foot and Ankle

Numerous nerve disorders affect the foot and ankle, and specificity is essential for diagnosis. We review a systematic process to conduct a history and physical examination for nerve disorders and how to categorize these pathologies. Several common nerve-related pathologies of the foot and ankle are then described. Finally, we discuss systemic neurologic conditions which can cause symptoms in the foot and ankle. A vast array of treatment options exist for painful nerve lesions of the foot: both nonsurgical and surgical. Treatment options depend on the affected nerve's function and location within the foot. Essential nerves will be managed much differently than nonessential nerves. Also important to consider is whether this is the initial treatment, treatment following one recurrence, or treatment following multiple recurrences. After the proper diagnosis is made, consideration of these principles should allow for early and effective interventions to be made. Recalcitrant nerve conditions of the foot and ankle can represent a management challenge. As with primary nerve disorders, surgical management is warranted in cases where conservative management fails. Furthermore, patients may continue to experience neurologic complications or recurrence of symptoms even after surgical intervention, at which point further surgical procedures may be undertaken. Neurolysis, transection with or without containment, barrier procedures, and peripheral nerve stimulation are viable potential surgical options for patients with chronic or recurrent nerve pain, depending upon patient-specific underlying pathology.

Medial Cuneiform Opening-Wedge Osteotomy for the Treatment of Hallux Valgus

Background:

While proximal first metatarsal osteotomy combined with distal soft tissue realignment is accepted as standard treatment of moderate to severe hallux valgus with metatarsus primus varus, none of the described proximal metatarsal osteotomies address the hyper-obliquity of the first metatarsocuneiform joint. An opening-wedge osteotomy of the medial cuneiform can potentially correct the 1-2 intermetatarsal angle (IMA) in addition to normalizing the hyper-obliquity of the first tarsometatarsal (TMT) joint. The purpose of this study was to retrospectively review the early radiographic and clinical results of the use of a medial cuneiform opening-wedge osteotomy fixed with a low-profile wedge plate combined with distal soft tissue realignment for the treatment of hallux valgus.

Methods:

Fourteen feet (13 patients; 2 male and 11 female, average age 56 years, range 22-75) with hallux valgus underwent an opening-wedge osteotomy of the medial cuneiform fixed with a low-profile nonlocking wedge plate combined with distal soft tissue realignment. The mean preoperative hallux valgus angle (HVA) was 32 degrees and the IMA was 16 degrees. HVA, 1-2 IMA, proximal first metatarsal inclination (PFMI), and presence of osteoarthritis of the first TMT joint were assessed on preoperative and final postoperative radiographs. Final postoperative radiographs were also evaluated for radiographic union and hardware failure at an average of 7 months (range, 3-19 months) postoperatively.

Results:

A mean intraoperative correction of 19 degrees and 7 degrees was achieved for the HVA and IMA, respectively. The mean HVA was 22 degrees and the mean IMA was 11 degrees at the time of final follow-up. At final follow-up, a recurrence of the deformity was observed in 12/14 feet. There were 2 nonunions—one plate failure and one screw failure. No first TMT joint instability or arthritis was observed. All patients were ambulatory without assistive device in either fashionable or comfortable shoe wear.

Conclusion:

Medial cuneiform opening-wedge osteotomy resulted in unreliable correction of HVA and IMA at short-term follow-up with a high rate of early recurrence of hallux valgus deformity and a complication rate similar to that of the Lapidus procedure. This procedure cannot be recommended for addressing hallux valgus in the setting of increased obliquity of the first TMT joint.

Level of Evidence:

Level IV, case series.

Effect of early full weight-bearing after joint injury on inflammation and cartilage degradation

BACKGROUND

Early full weight-bearing after an acute osteochondral injury avoids problems associated with immobility but may also be harmful by amplifying the inflammatory response. To investigate these effects, we developed an in vivo model of subchondral trauma.

METHODS

After an impact injury to the femoral condyle, fourteen dogs were randomized to immediate full weight-bearing or to four weeks of minimal weight-bearing before full weight-bearing. Synovial fluid was sampled by aspiration at one, two, four, eight, twelve, sixteen, twenty, and twenty-four weeks. Neutrophils, monocytes, and lymphocytes were enumerated, and the concentrations of tumor necrosis factor-alpha, interleukin-10, nitric oxide, matrix metalloproteinases, and glycosaminoglycans were measured.

RESULTS

Compared with the findings for uninjured joints, the synovial fluid from the impacted joints of full-weight-bearing dogs had significantly higher peak concentrations of neutrophils (p = 0.0006 at one week), mononuclear leukocytes (p = 0.001 at four weeks), tumor necrosis factor-alpha (p = 0.001 at one week), nitric oxide (p = 0.001 at one week), matrix metalloproteinases (p = 0.008 at one week), and glycosaminoglycans (p = 0.002 at four weeks and p = 0.001 at six months). The size of the bone bruise correlated with the peak concentrations of tumor necrosis factor-alpha (r2= 0.89, p = 0.007; Spearman rank test), matrix metalloproteinases (r2= 0.96, p = 0.0004), and glycosaminoglycans (r2= 0.96, p = 0.0004). However, restriction to minimal weight-bearing for four weeks after the injury led to a significant reduction in the synovial fluid concentrations of neutrophils (p = 0.007 at one week and p = 0.01 at two weeks), tumor necrosis factor-alpha (p = 0.0006 to 0.02 during the first four weeks), nitric oxide (p = 0.001 to 0.04 during the first four weeks), and matrix metalloproteinases (p = 0.007 to 0.01 from the second week to the eighth week). In contrast, interleukin-10 concentrations were significantly higher (p = 0.002 at one week) and glycosaminoglycan levels remained at normal levels in animals that were restricted from immediate full weight-bearing after the injury.

CONCLUSIONS

The magnitude of the inflammatory response is proportional to the size of the bone bruise. Restriction to minimal weight-bearing for four weeks reduces the magnitude of the inflammatory response and the cartilage degradation following articular cartilage impact injury.

CLINICAL RELEVANCE

Strategies to minimize mechanical stress during the early postinjury period may help to preserve cartilage integrity and forestall the development of osteoarthritis.

Cellular events leading to chondrocyte death after cartilage impact injury

OBJECTIVE

We undertook this study to test our postulate that leukocytes extend the zone of injury in cartilage after acute mechanical trauma.

METHODS

Fresh cadaveric canine femoral condyles were subjected to 20-25-MPa impact injury. Condyle explants or dispersed chondrocytes were cultured with autologous blood mononuclear leukocytes (MNLs). Viability of chondrocytes at varying distances from the impact site was assessed by trypan blue exclusion.

RESULTS

Mechanical injury caused a significant loss of viable chondrocytes over 7 days, even in cartilage >10 mm from the impact site. After biomechanical stress, death of cells within 10 mm of the impact could be largely prevented by addition of N(G)-monomethyl-L-arginine to inhibit nitric oxide (NO) generation. Chondrocytes within 10 mm of the impact were also susceptible to killing by living MNLs, but not by incubation with the supernatants of endotoxin-activated MNLs. Chondrocytes in this vulnerable zone expressed intercellular adhesion molecule 1 (ICAM-1) (CD54), facilitating attachment of MNLs that localized adjacent to the chondrocytes. Leukocytes killed dispersed chondrocytes harvested from the impact zone by generation of reactive oxygen species. Leukocyte-mediated killing could be blocked by desferoxamine or by antibodies to CD18, which prevent attachment of leukocytes to ICAM-1-expressing chondrocytes.

CONCLUSION

Our data suggest that after mechanical injury, chondrocytes distant from the site may be killed through the generation of NO. Inflammatory leukocytes further extend the zone of chondrocyte death by adhering to chondrocytes expressing ICAM-1 and by inducing the accumulation of free oxygen radicals in the chondrocyte cytoplasm. Patients may benefit from therapies that reduce infiltration of inflammatory leukocytes into acutely injured cartilage.