Tibialis Anterior Tendon Reconstruction Utilizing Split Tendon Turn-down: A Case Report and Technique Guide

Tibialis anterior tendon (TAT) ruptures are rare, equating to less than 1% of all musculotendinous injuries. These injuries can be acute or atraumatic, with the latter often associated with chronic degenerative tendinopathy. Surgical repair is indicated when conservative measures fail in meeting functional demands. Direct end-to-end repair is the preferred method for TAT ruptures but may not be feasible with a large tendon defect. Various surgical techniques have been described to address this pathology, including allograft tendon interposition or extensor hallucis longus (EHL) transfer. The authors present a unique technique utilizing a minimal incision TAT turn-down with dermal matrix allograft augmentation, and, in addition, a case implementing this technique in a patient with a large insertional defect. The patient's postoperative course and outcomes were favorable, with improvements in pain, satisfaction, functional scores, and strength. The surgical technique offers versatility and can be adapted to different tendon defect sizes. It also allows for minimal-incision exposure, beneficial for patients with comorbidities or compromised skin integrity. In conclusion, the authors present a case report and surgical technique for the management of large-deficit, chronic TAT ruptures using split TAT turn-down. This technique provides a potential solution for cases where direct end-to-end repair is not feasible.Level of Evidence: Level V.

The Role of Epigenomics in Mapping Potential Precursors for Foot and Ankle Tendinopathy: A Systematic Review

Tendinopathy of the foot and ankle is a common clinical problem for which the exact etiology is poorly understood. The field of epigenetics has been a recent focus of this investigation. The purpose of this article was to review the genomic advances in foot and ankle tendinopathy that could potentially be used to stratify disease risk and create preventative or therapeutic agents. A multi-database search of PubMed, Cochrane, Google Scholar, and clinicaltrials.gov from January 1, 2000 to July 1, 2022 was performed. A total of 18 articles met inclusion and exclusion criteria for this review. The majority of such research utilized case-control candidate gene association to identify different genetic risk factors associated with chronic tendinopathy. Polymorphisms in collagen genes COL5A1, COL27A1, and COL1A1 were noted at a significantly higher frequency in Achilles tendinopathy versus control groups. Other allelic variations that were observed at an increased incidence in Achilles tendinopathy were TNC and CASP8. The extracellular matrix (ECM) demonstrated macroscopic changes in Achilles tendinopathy, including an increase in aggrecan and biglycan mRNA expression, and increased expression of multiple matrix metalloproteinases. Cytokine expression was also influenced in pathology and aberrantly demonstrated dynamic response to mechanical load. The pathologic accumulation of ECM proteins and cytokine expression alters the adaptive response normal tendon has to physiologic stress, further propagating the risk for tendinopathy. By identifying and understanding the epigenetic mediators that lead to tendinopathy, therapeutic agents can be developed to target the exact underlying etiology and minimize side effects.Level of Evidence: Level IV: Systematic Review of Level II-IV Studies.

Inadequate Purchase in the Proximal Tendon Stump Using the Percutaneous Achilles Repair System: A Technical Tip

Minimally invasive approaches for the Achilles tendon have emerged as viable alternatives for acute Achilles ruptures, with several potential benefits in comparison to the open approach. Occasionally, proper purchase in the proximal tendon stump is not achieved due to severe degenerative disease of the tendon. In this article, we present a technique in which a small accessory incision is used during percutaneous Achilles repair in order to pass the sutures in a more proximal and healthy area of the tendon. This technique is useful for situations in which adequate tendon grasp is not obtained, avoiding the need of conversion to an open approach.Level of Evidence: Level V: Expert opinion.

An Operational Definition of First Ray Hypermobility

BACKGROUND

The first ray (metatarsocuneiform) behaves as a load-bearing strut in supporting weight. Due to its functional importance, stress-testing techniques are used to assess the stability of the first ray and objectify evidence of hypermobility. The test and measurement of first ray hypermobility (FRH) is of interest to clinicians and researchers. The condition itself, however, has proven elusive to diagnose. This article defines FRH for the purpose of improving the consistency by which the diagnosis is made. Currently, the lack of a consensus definition prevents research from determining the incidence rates and prevalence of FRH, a commonly reported medical condition.

THE DEFINITION

Symptomatic FRH presents as dorsal displacement that measures greater than 8 mm, accompanied with signs and symptoms consistent with loading insufficiency of the first ray. The operational definition is objective and if adopted across health care professions, the criterion could become the standard for identifying FRH in patients and research participants.

LEVEL OF EVIDENCE

Level V, expert opinion.

Avascular Necrosis of the Talus Following Subchondroplasty: A Case Report and Review of Literature

CASE

Avascular necrosis (AVN) of the talus in a 45-year-old female following subchondroplasty with calcium phosphate bone filler for treatment of anterolateral and posteromedial talar dome bone marrow lesions (BMLs). The patient subsequently presented as consultation, 18 months postoperatively, with AVN of the talus. After failing conservative management, the patient underwent a total ankle arthroplasty at 46 months after subchondroplasty with resolution of pain.

CONCLUSION

There are few studies that have reported on the safety of subchondroplasty of the talus. Given the tenuous blood supply to the talar body and poor patient outcomes associated with AVN, caution should be taken before extrapolating the generally positive results of subchondroplasty in the knee.

LEVEL OF EVIDENCE

Level IV.

Radiographic and Cadaveric Analysis of Minimally Invasive Bunionectomy Osteotomy Position-"MIS Bunion Sweet Spot"

Minimally invasive surgery (MIS) is a growing technique that favors faster recovery and cosmetic results. We propose a recommended osteotomy position or "MIS Sweet Spot" to make the procedure more reproducible and lessen the learning curve to improve outcomes. A total of 211 patients from 3 surgeons between 2 different study centers were included in a retrospective radiograph measurement analysis and a cadaveric dissection to confirm the safety of nearby anatomical structures. An average distance of 2.2 cm proximal from the first metatarsophalangeal joint was found as the "Sweet Spot" to perform the transverse osteotomy. At this distance, neurovascular and tendinous structures were unharmed and the osteotomy remained extracapsular. Furthermore, an average of 10.7° of intermetatarsal angle reduction and a reduction of tibial sesamoid position of 3 points were achieved. A predictable and measurable distance for osteotomy placement will help to provide more confidence in producing the bunionectomy osteotomy with the specialized tools used in MIS and can help to reduce operative time and improve results.Level of Clinical Evidence (LOCE): 3.

High-Energy Achilles Tendon Rupture With Associated Medial Malleolus Fracture and Traumatic Peroneal Dislocation: A Case Report

Fracture, Achilles tendon rupture, or traumatic dislocation of the peroneal tendons are often seen in isolation after a trauma or sports-related injury. However, in rare circumstances, a combination of these injuries can occur simultaneously. Multiple previous case reports describe a combination of 2 of these injuries. Missed or delayed diagnosis is common in these combination injuries and can lead to significant patient morbidity and result in long-term consequences. We report a case of a 35-year-old man who sustained an Achilles tendon rupture with an associated medial malleolus fracture and traumatic peroneal dislocation after a snowboarding injury. These injuries were treated surgically, and at 9 months postoperatively, the patient had returned to all activities. Clinicians should have a high index of suspicion for concomitant injuries with higher-energy trauma to the ankle and should perform a thorough history, physical examination, and plain radiographs at a minimum.Levels of Evidence: LEVEL 5.

Early Results of a Novel Intramedullary Fixation Device for Proximal Fifth Metatarsal Fractures

BACKGROUND

Proximal fifth metatarsal fractures are commonly treated surgically due to their poor healing capacity. While intramedullary screws may be the most popular operative treatment choice, newer fixation methods continue to develop. We present a case series utilizing a novel intramedullary fixation device for proximal fifth metatarsal fractures. To our knowledge, no other study in the literature has assessed the safety and efficacy of this fixation method.

METHODS

A retrospective analysis was performed for 16 patients with proximal fifth metatarsal fractures who underwent fixation with the same novel intramedullary device. Patient charts were reviewed for fracture union, plantar fracture gapping, time to weight-bearing, refracture, perioperative complications, and secondary surgeries.

RESULTS

Sixteen patients with an average age of 43.3 years underwent fixation with this novel device from 2015 to 2020. Mean follow-up was 32.4 weeks. Fifteen of the 16 patients achieved radiographic union at a mean of 8.9 weeks. One patient suffered a nonunion. Mean time to full weight-bearing in, and out of, a walking boot was 6.4 and 9.8 weeks, respectively, for healed fractures. Mean plantar fracture gap improved from 1.22 mm to 0.88 mm following surgery. There were zero infections, refractures, or hardware complications. Three patients suffered iatrogenic fracture during implant insertion.

CONCLUSION

To our knowledge, this is the first report of early results for this novel intramedullary device. Excellent union rates, acceptable time to weight-bearing, and a low complication profile can be achieved. Based on our findings, we propose a safe and effective treatment option for proximal fifth metatarsal fractures.

LEVELS OF EVIDENCE

Level IV: Clinical case series.

Fibular Rod Osteosynthesis in Ankle Fractures With Compromised Soft Tissue

BACKGROUND

Complications after plate and screw fixation of ankle fractures are frequently reported in the literature, with a higher rate in patients with advanced age, comorbidities, and poor skin conditions. A reduced complication rate has been reported with intramedullary nailing (IMN) of the fibula; however, the indication has been based on the surgeon's preferences. We report the results after IMN in patients with compromised soft tissue exclusively.

METHODS

A total of 71 patients with 72 distal fibula fractures were included in this retrospective study. Information about medical history, the ankle injury, treatment, and complications were collected from the medical records. Additionally, the preinjury and 6-week follow-up radiographs were evaluated.

RESULTS

Postoperative information was available for a minimum of 4.3 years postoperatively or until death. In all, 10 patients had complications related to the nail and required secondary surgery. These included 6 symptomatic hardware issues, 2 construct failures, 1 deep infection, and 1 combined deep infection and construct failure.

CONCLUSIONS

After IMN of the fibula, 14% of the patients required reoperation. Our results support the previous literature suggesting IMN as an acceptable surgical alternative where the risk of complications with plate and screw fixation is considered too high. Compromised soft tissue is one important indication.

LEVEL OF EVIDENCE

Level IV: Case series without control.

Intramedullary Fixation of Distal Fibula Fractures

BACKGROUND

Ankle fractures pose a unique challenge to the treating orthopedic surgeon. Intramedullary (IM) distal fibula fixation is a relatively newer entity offering a viable option to minimize wound complications while providing similar outcomes. Our study utilizes an IM nail featuring proximal fixation via IM talons ensuring maintenance of fracture reduction this is the largest case series utilizing this novel device assessing time to weight-bearing (WB) and fracture union in addition to the safety and reproducibility of percutaneous reduction.

METHODS

A retrospective case series was conducted on 51 ankle fractures treated with a single IM device for lateral malleolar fixation. Postoperative radiographs were assessed, qualifying reductions as good, fair, or poor based on a reduction classification. Patient charts were reviewed for fracture characteristics, reduction method, fracture union, time to WB, and complications.

RESULTS

Mean follow-up time was 32.2 weeks; 47 fracture reductions (92%) were classified as good, and 4 (8%) were fair. All but 1 fracture (98%) went onto union. Average time to union was 10.3 weeks. Average time to WB with and without a walking boot was 6.8 and 11.2 weeks, respectively. Two patients experienced painful hardware. One patient had a superficial wound infection.

CONCLUSION

When evaluating this novel IM device, fracture union and time to union were found to be acceptable, with minimal wound or other complications. Percutaneous reduction permitted good fracture reduction quality. Consistent time to WB for a variety of fractures was reliably demonstrated following operative fixation with this device, including those in the elderly population.

LEVELS OF EVIDENCE

Level IV: Clinical case series.

The Ellis Jones Method of Treating Chronic Peroneal Subluxation: Revisited and Colorized After 87 Years

Chronic cases of peroneal subluxation typically call for surgical treatment; however, research on current surgical procedures suggests nonuniformity. The purpose of this study is to remind surgeons of the efficacy of an older surgical method by using the case of a selected patient. In this study, the Ellis Jones procedure was performed on a patient who had been suffering from a chronic peroneal subluxation for 22 years, since, in this particular case, other approaches were deemed likely to be unsuccessful. The patient had hypertrophied, frayed, and swollen tendons, which were unsuitable to be rerouted, whereas the superior peroneal retinaculum was diminished and deepening procedures would not be able to establish sufficient volume for retaining the hypertrophied tendons. After the debridement and repair of the peroneal tendons, ¼ of the lateral Achilles tendon was split, passed through a hole in the fibula, and sutured onto itself, and the subluxation path of the peroneal tendons was closed with an effective tendon barrier. The patient returned to work after 8 weeks of the surgery and was followed up for 4 years postoperatively. On selected patients, the Ellis Jones surgical method might therefore still be applied.Levels of Evidence: Level V.

Systematic Review of Nonoperative Functional Protocols for Acute Achilles Ruptures Utilizing a Formal Rehabilitation Protocol Showing Lowest Rerupture Rates

AIM

To lay out a comprehensive protocol for practitioners and physical therapists that has the lowest rerupture rates for nonoperative treatment of acute Achilles ruptures.

METHOD

Relevant articles were searched in PubMed, CINAHL Plus, and Cochrane Library using keyword combinations: nonoperative AND/OR Achilles rupture AND functional AND/OR protocol or functional AND/OR rehabilitation. To be included in the full analysis, the studies had to have detailed functional protocols with physical therapy program details and outcome scores of rupture rates and/or Achilles Tendon Rupture Score (ATRS). We ultimately found 7 articles that fit our inclusion criteria for analysis. All of them had rerupture rates, and 4 had ATRS scores and functional protocols with mention of formal physical therapy programs.

RESULTS

Lowest rerupture rates were found in strict functional rehabilitation protocols that were full weightbearing in boot immediately at full equinus or 30° plantar flexed. They started active range of motion at 5 to 8 weeks and started formal physical therapy at 10 weeks.Levels of Evidence: Level III: Evidence obtained from well-designed non-experimental descriptive studies.

Timing of Open Reduction and Internal Fixation of Ankle Fractures

Background. Unstable ankle fractures are treated with open reduction internal fixation (ORIF) to prevent posttraumatic arthritis. Typically, ORIF is performed as an ambulatory surgery several days to a few weeks after injury. It is unclear what effect this delay may have on functional outcome. This study aimed to assess the effect of timing of ankle ORIF on wound complications and functional outcome. Methods. A retrospective review of 121 patients who underwent ankle ORIF was performed. A total of 58 patients had a follow-up of at least 24 months. Time between injury and surgery greater than 14 days was defined as "delayed." Demographic variables, injury characteristics, length of surgery, and postoperative stay were documented. Comparison of demographic variables, wound complications, and functional outcome determined by Foot and Ankle Outcome Score (FAOS) was performed. Results. 118 patients were included. The duration between injury and surgery was 6 days in the "early" group and 19 days in the "delayed" group. There were no significant differences in demographic variables, injury characteristics, and length of surgery between the groups. Wound complications in the early and delayed groups were 5% and 11.8%, although this difference was not statistically significant. Among 58 patients who had a follow-up of at least 24 months, the median follow-up time was 38 (range, 24-76) months. Each subscale of FAOS demonstrated no significant difference. Conclusion. Ankle ORIF more than 14 days after injury did not significantly increase the rate of wound complication, nor did it impair ultimate functional outcome in this group. Levels of Evidence: Level III.

Wound-Healing Issues Following Rotational Ankle Fracture Surgery: Predictors and Local Management Options

Background. The incidence and risk factors of wound-healing complications following rotational ankle fracture surgery are well documented in the literature. However, there is a paucity regarding management options following these complications. The goal of this study was to provide a descriptive analysis of one surgeon's experience managing wound complications in patients who have undergone ankle fracture surgery. Methods. A total of 215 patients who were operatively treated for an unstable ankle were retrospectively identified. Patient demographics, medical histories, initial injury characteristics, surgical interventions, and clinical follow-up were collected. Twenty-five of these patients developed postoperative wound problems. Results. Of the original cohort of 215 patients, 25 (11.6%) developed wound-healing complications. Their average age was 53.6 ± 18.0 years; there were 12 males (48.0%). Connective tissue/inflammatory disease (odds ratio [OR] 3.9), cardiovascular disease (OR 3.6), and active smoking (OR 3.3) were associated with an increased likelihood of developing postoperative wound complications. With regard to injuries, open fractures (OR 17.9) had the highest likelihood of developing postoperative complications, followed by type 44-C (OR 2.8) and trimalleolar fractures (OR 2.0). Conclusion. Wound complications following open treatment of ankle fractures occurred with an incidence of 11.6% in this series, of which only about half required operative intervention. A third of wounds were managed by orthopaedics in conjunction with plastic surgery. Levels of Evidence: Level III: Retrospective comparative study.

Incarcerated Plantar Dislocation of the First Metatarsophalangeal Joint: Reduction Using Intra-articular Saline Injection

Plantar dislocation of the first metatarsophalangeal (MTP) joint is exceedingly rare, and in prior reported cases, simple closed manipulation easily enabled reduction. We present here the first reported plantar dislocation that failed closed manipulation. We also report a technique involving injection of saline into the joint to facilitate reduction. The saline insufflation likely relieves buttonholing of the metatarsal head through the dorsal joint capsule. For first MTP joint plantar dislocations that fail reduction with manipulation, we recommend attempting injection of the joint with saline prior to subjecting the patient to open reduction.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case report.

Utility of Third-Week Postoperative Radiographs in the Management of Ankle Fractures

OBJECTIVES

To evaluate the costs and efficacy of radiographs taken in the third week after fixation of bimalleolar and trimalleolar fractures.

PATIENTS AND METHOD

A retrospective evaluation was made of patients who underwent surgical fixation because of bimalleolar and trimalleolar fractures between January 1, 2008, and October 1, 2013. Patient demographics (age, gender, body mass index), fracture type, follow-up periods, and fixation methods were recorded, and the radiographs taken on postoperative day 1, at 3 weeks, 6 weeks, and the final follow-up were examined by 2 orthopedists. Measurements were taken of the medial clear space (MCS ≤ 4 mm), the tibiofibular clear space (TFCS < 5 mm), and the talocrural angle (TCA = 83° ± 4°) on the mortise radiograph and of the overlap between the tibial tubercle and fibula (TFO > 10 mm) on the anteroposterior radiograph; residual step (mm) was measured on the lateral radiograph.

RESULTS

A total of 263 patients were examined, and of these, 112 were included for evaluation. In the measurements of postoperative day 1, third week, and sixth week and the final radiographs, no statistically significant difference was determined in the MCS, TFCS, TCA, TFO, and residual step values. Because the cost of a series of 3-way ankle radiographs in Turkey is US$3.81 per patient, the cost of the control series for the 112 patients in this study was US$ 427.3.

CONCLUSIONS

In patients treated surgically for bimalleolar and trimalleolar fractures, the radiographs taken in the third week rarely resulted in a change of patient management. Therefore, it simply constitutes an additional cost for the patient or the hospital.

LEVELS OF EVIDENCE

Level III: Retrospective Cohort study.

Double Plating of Distal Fibula Fractures

INTRODUCTION

Distal fibula fractures are common orthopaedic injuries that often require open reduction internal fixation (ORIF) to anatomically reduce the fracture and minimize the risk of posttraumatic arthritis. In certain clinical situations, stouter fixation may be advantageous to decrease the risk of fixation failure. In this study, the authors report on 12 patients who underwent distal fibula ORIF with 2 one-third tubular plates.

MATERIALS AND METHODS

Twelve consecutive patients who underwent distal fibula ORIF with 2 one-third tubular plates were retrospectively reviewed. Clinical and radiographic outcomes were reviewed, and functional outcomes were obtained using the Foot and Ankle Outcome Score (FAOS). Institutional review board approval was obtained.

RESULTS

All 12 fractures healed clinically and radiographically. One patient was lost to follow-up after healing of the fracture. One patient had removal of fibular hardware at 15 months after surgery. Ten patients had no hardware related pain and good ankle function. FAOS scores were obtained at a mean of 25.6 months after surgery and were as follows: pain (87.6, SD = 9.5), activities of daily living (90.4, SD = 14.5), symptoms (93.3, SD = 9.5), sports (89.5, SD = 18.1), and quality of life (57.4, SD = 21.3).

CONCLUSIONS

Double plating of distal fibula fractures is a viable technique for problem fractures that potentially provides a readily accessible, low-cost alternative to other means of enhancing fixation.

LEVELS OF EVIDENCE

Level IV.

Division Tenorrhaphy: A Novel Technique for Chronic or Failed Nonoperatively Treated Achilles Tendon Rupture

Here we describe a modified open technique for the repair of a ruptured Achilles tendon using multiple looped sutures with the creation of interdigitating tendon stumps maximizing surface area for suture application as well as allowing for significant tissue overlay. This technique produces a high strength repair that is useful in cases of extensive degeneration or poor-quality tissue. Degenerative tissue may be encountered with chronic ruptures or failed nonoperative treatment, as well as those ruptures that occur at the proximal myotendinous junction. We present 2 cases in which the technique was utilized: one of a failed nonoperatively treated rupture and another of a chronic rupture. The technique was found to be successful for both patients with improvement in visual analogue scale, Achilles tendon total rupture score, American Orthopaedic Foot and Ankle Score, and Foot and Ankle Disability Index.

LEVELS OF EVIDENCE

Level IV.

Vitamin D in Foot and Ankle Fracture Healing: A Literature Review and Research Design

Vitamin D is a generic name for a group of essential vitamins, or secosteroids, important in calcium homeostasis and bone metabolism. Specifically, efficacy of vitamin D with regard to bone healing is in question. A literature review was performed, finding mostly large studies involving vitamin D effects on prevention of fractures and randomized animal model studies consisting of controlled fractures with vitamin D interventions. The prevention articles generally focus on at-risk populations, including menopausal women and osteoporotic patients, and also most often include calcium in the treatment group. Few studies look at vitamin D specifically. The animal model studies often focus more on vitamin D supplementation; however the results are still largely inconclusive. While recent case reports appear promising, the ambiguity of results on the topic of fracture healing suggests a need for more, higher level research. A novel study design is proposed to help determine the efficacy on vitamin D in fracture healing.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Systematic Review.

A single platelet-rich plasma injection for chronic midsubstance achilles tendinopathy: a retrospective preliminary analysis

The purpose of this study was to evaluate a series of patients undergoing a single platelet-rich plasma (PRP) injection for the treatment of chronic midsubstance Achilles tendinopathy, in whom conservative treatment had failed. Thirty-two patients underwent a single PRP injection for the treatment of chronic midsubstance Achilles tendinopathy and were evaluated at a 6-month final follow-up using the Foot and Ankle Outcome Score and Short Form 12 general health questionnaire. Magnetic resonance imaging was performed on all patients prior to and 6 months after injection. Twenty-five of 32 patients (78%) reported that they were asymptomatic at the 6-month follow-up visit and were able to participate in their respective sports and daily activities. The remaining 7 patients (22%) who reported symptoms that did not improve after 6 months ultimately required surgery. Four patients went on to have an Achilles tendoscopy, while the other 3 had an open debridement via a tendon splitting approach. A retrospective evaluation of patients receiving a single PRP injection for chronic midsubstance Achilles tendinopathy revealed that 78% had experienced clinical improvement and had avoided surgical intervention at 6-month follow-up.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Retrospective case series.

Atypical stress-avulsion fracture of the Lisfranc joint complex

Antiphospholipid syndrome and systemic erythematosus have been associated with metatarsal stress fractures. Stress fractures of the Lisfranc joint complex are uncommon injuries but have been reported to occur most frequently in ballet dancers. We present a case of an avulsion fracture of the Lisfranc joint complex that occurred spontaneously. We have reviewed the association between systemic conditions and metatarsal fractures and proposed a series of hypothetical pathological events that may have contributed to this unusual injury.