Operative Time, Cost, and Union Rate of Power Rasp Joint Preparation Versus Traditional Preparation in Arthrodesis of the Foot and Rearfoot.

Time spent in the operating room is valuable to both surgeons and patients. One of the biggest rate-limiting factors when it comes to arthrodesis procedures of the foot and ankle is cartilage removal and joint preparation. Power instrumentation in joint preparation provides an avenue to decrease joint preparation time, thus decreasing operating room time and costs. Arthrodesis of 47 joints (n) from 27 patients were included. Power rasp joint preparation in 26 joints was compared to traditional osteotome and curette joint preparation in 21 joints in both time (seconds), cost (total operating room time cost per minute), and union rate. The overall mean joint preparation time using power rasp for the subtalar joint was 268.3 seconds, talonavicular joint 212.3 seconds, calcaneocuboid joint 142.6 seconds, 1st TMT 107.2 seconds. Mean joint preparation time using traditional method for subtalar joint 509.8 seconds, talonavicular joint 393.0 seconds, calcaneocuboid joint 400.0 seconds, 1st TMT 319.6 seconds. Mean cost of joint preparation using power rasp for subtalar joint $165.47, talonavicular joint $130.89, calcaneocuboid joint $87.94, 1st TMT $66.11. Mean cost of joint preparation using traditional techniques for subtalar joint $314.34, talonavicular joint $242.35, calcaneocuboid joint $246.67, 1st TMT $197.33. Overall union rate was 98% (1 asymptomatic non-union). Increasing efficiency in the operating room is vital to every surgeon's practice. Power rasp joint preparation is a viable option to increase efficiency and decrease operative time, this study shows no statistically significant differences in union rate, with comparable rates to existing literature.

Two-Year Outcomes After Total Ankle Replacement With a Novel Fixed-Bearing Implant By a Single Surgeon Non-Inventor.

Total ankle arthroplasty continues to gain popularity amongst surgeons and patients as an alternative to arthrodesis. Historically the designs of early implants were plagued with complications and frequently abandoned. Since that time the procedure and materials have undergone significant advancements in both surgical approach as well as design and function of the available implants. In this study, 40 consecutive patients who received a semiconstrained prosthesis with a unique fixed-bearing polyethylene insert were identified. Minimum follow-up was 2 y. Demographic, social, and past medical data was retrospectively reviewed. Concomitant procedures were also recorded. Radiographic analysis included lateral ankle radiograph postoperative range of motion (ROM) with maximum dorsiflexion and maximum plantarflexion weight bearing at the most recent clinic visit. Clinical outcomes included VAS, FFI, and AOFAS scores. Lateral radiographs taken in the office at a minimum 2-y follow-up showed mean maximum dorsiflexion of 11.8 degrees and plantarflexion of 13.9 degrees. VAS, FFI, and AOFAS scores improved from 8.1, 92.9, and 44.8 to 1.4, 15.3, and 90.1 postoperatively, respectively. A total of 2.5% (n = 1) required revision surgery for poly failure, and 5.0% (n = 2) underwent local wound care in the office setting postoperatively and healed without complications. Overall survivorship was 97.5% at the minimum follow-up of 2 y. In conclusion, similar studies have reported survivorship from 90% to 100% with modern ankle implants in short to mid-term follow-up. Although this is a small sample size, our data shows a 97.5% survivorship at 2 y postoperatively with favorable patient-reported statistically significant functional outcome scores, and ankle range of motion consistent with existing literature.

Medium-Term Outcomes of the Arthroscopic Brostrom Procedure: A Retrospective Analysis of 66 Patients.

The arthroscopic Brostrom procedure is a minimally invasive technique that is a viable option surgeons have to treat patients with chronic lateral ankle instability (CAI). Our hypothesis was that there will be a statistically significant difference in pre- and postoperative scores and that patient satisfaction scores remained consistent at a minimum of 5 years postoperatively. Preoperative American Orthopedic Foot and Ankle (AOFAS) hindfoot scores, visual analog scale (VAS), foot function index (FFI) were compared with postoperative scores. Karlsson-Peterson (KP) scores were assessed at the final follow-up. Unpaired t tests were performed to determine if there was a statistically significant difference in AOFAS, VAS and FFI scores. Mean preoperative scores were (AOFAS) 51.8, (VAS) 7.36, and (FFI) 83.5, respectively. At the 5-year mark, the postoperative scores were 88.9, 2.24, 18.4 respectively and 83.6, for the KP scores. Furthermore, we compared those patients with a BMI <30 kg/m2 to those with a BMI ≥30 kg/m2. This comparison showed no statistically significant postoperative difference between groups at 5 years. The aim of the study was to determine the longevity of the procedure based on 5-year outcomes scores comparing preoperative and 5+-year AOFAS, VAS, and FFI scores. We found that there was a significant difference in all scores which suggests that this repair provides adequate relief of pain and improved outcomes at 5 years.

Postoperative Magnetic Resonance Evaluation of Anterior Talofibular Ligament Following Arthroscopic Brostrom Procedure: Analysis and Outcomes of 40 Repairs at 12 Months.

Lateral ankle sprains are one of the most common orthopedic injuries. When conservative treatment fails, surgical correction is often performed using either open or arthroscopic techniques. We hypothesize that MRI evaluation of the arthroscopic brostrom repair will show intact repair and decrease in thickness of the anterior talofibular ligament (ATFL) at 1 year, with statistically significant improvement of patient function and pain scores. Postoperative MRI was utilized at minimum 1-year follow-up to evaluate the integrity of the arthroscopic brostrom repair, as well as comparison of ATFL thickness to literature validated average thickness. A musculoskeletal fellowship trained radiologist performed all MRI reads. In addition, 3 fellowship trained foot and ankle specialists from a single institution all performed measurements of the ATFL. Surgical satisfaction using 1 to 100 scale, and Karlsson-Peterson (KP) were measured at 1 year postoperatively. In addition, pre- and postoperative Foot Function Index (FFI), American Orthopedic Foot and Ankle (AOFAS) hindfoot scores, and Visual Analog Scale (VAS) were measured using unpaired t tests. All repairs were shown to be intact at minimum 1-year follow-up via MRI evaluation, with ATFL thickness of 2.21 mm. Preoperative FFI, AOFAS, and VAS were 54.9, 46.4, and 7.1 respectively. Postoperative scores were 11.0, 91.7, and 1.3 respectively. Surgical satisfaction was 88.2, KP was 75.3. Comparison of pre- and postoperative scores (VAS, FFI, AOFAS) were shown to be statistically significant, p < .05. No significant difference in demographic data was observed at 1 year. The data from this study offers evidence that the arthroscopic brostrom repair provides patients with good outcomes as well as an intact ATFL with normal morphology at 1 year postoperatively.

Landmarks for a Minimally Invasive Approach for Haglund's Deformity: A Cadaveric Study.

INTRODUCTION: Haglund's deformity is a posterosuperior calcaneal prominence often associated with a painful bursa and insertional Achilles tendinopathy. Endoscopic debridement has been previously described; however, the aim of this cadaveric study is to describe landmarks of a minimally invasive surgical (MIS) approach to Haglund's deformity. METHODS: Twelve specimens were dissected to identify medial and lateral portals for minimally invasive burr placement and anchor placement. A standard ruler was used to measure the distance in millimeters from the medial and lateral neurovascular structures in relation to medial and lateral portals. A separate 7-cm longitudinal incision posterior to the lateral malleolus and a separate 7-cm longitudinal incision posterior to the medial malleolus were made to identify at-risk neurovascular structures. RESULTS: The average distance from the sural nerve to the lateral portal was 25.7 mm (23-26). The mean distance from the lateral calcaneal branch of the sural nerve to lateral portal was 11.4 mm (10-12). The mean distance from the tibial nerve to the medial portal was 35.3 mm (35-36). Both the medial and lateral incisions were 9.3 mm from the calcaneal tuberosity. CONCLUSION: The results indicate that the MIS approach to Haglund's deformity resection can be performed reliably without neurovascular compromise. LEVELS OF EVIDENCE: Level IV.

Management of Talar Avascular Necrosis with Total Talus.

Avascular necrosis (AVN) of the talus is a difficult pathology to treat. Patient-specific factors such as functional status, comorbidities should be considered. Previous standard care for talar AVN was centered around arthrodesis procedures and loss of motion about the joints of the rearfoot and ankle. With the advent of 3D printed talar implants, patients are afforded an option to maintain ankle joint motion. Literature is limited due to the recent development of total talus replacement (TTR) technology. This article aims to review literature, surgical techniques, and pearls to better help foot and ankle surgeons treat cases of talar AVN.

Arthroscopic Lateral Stabilization.

The indications and procedures for arthroscopy of the ankle and subtalar joints continues to increase. Lateral ankle instability is a common pathology that may require surgery to repair injured structures of patients nonresponsive to conservative management. Common surgical methods generally include ankle arthroscopy with subsequent open approach to repair/reconstruct the ankle ligament(s). This article discusses two different approaches to repairing lateral ankle instability through an arthroscopic approach. The arthroscopic modified Brostrom procedure creates a strong repair with minimal soft tissue dissection, and is a reliable, minimally invasive approach to lateral ankle stabilization. The arthroscopic double ligament stabilization procedure creates a robust reconstruction of the anterior talofibular and calcaneal fibular ligaments with minimal soft tissue dissection.

Midterm Outcomes of Endoscopic Plantar Fascia Debridement in 125 Patients: A 5-Year Follow-Up.

Plantar fasciitis is one of the most common pathologies addressed by foot and ankle surgeons. Despite advances and overall success rates for conservative therapy, many of the recalcitrant cases proceed to require surgical correction. Partial to complete release of the fascia is often performed altering foot biomechanics and severing the windlass mechanism. Endoscopic debridement of the plantar fascia allows for direct visualization and removal of the inflammatory tissue while leaving the fascia and its function intact. A total of 125 feet were evaluated with a minimum follow-up time of 5 years. Gender, body mass index, and duration of symptoms were all evaluated and documented. Visual analog scale scores (VAS), American Orthopedic Foot and Ankle Score (AOFAS), and Foot Function Index (FFI) were collected both pre- and postoperatively. AOFAS, FFI, and VAS scores improved from a pre-operative mean of 57.6, 89.4%, and 8.6-89.1, 13.4%, and 0.7 respectively (p < .05) at final follow-up. Of the 125 patients, 98% stated they were satisfied with the operative outcome and would undergo the procedure again. At final follow-up, no patient suffered rupture of the fascia or recurrence. Patients were able to bear weight immediately following the surgery in a walking boot and on average patients were able to return to work at 3.4 days following surgery. This is a novel technique that does not compromise the plantar fascia or alter foot biomechanics with promising 5-year outcomes.

Lesser Metatarsophalangeal Plantar Plate Repair.

Lesser toe plantar plate injuries at the metatarsophalangeal (MTP) joint are a common source of metatarsalgia. Chronic pain with weight-bearing is the common presentation of lesser toe instability. Deformity occurs when the plantar plate is torn or attenuated. Crossover toe and MTP instability often occur with multiplane deformity, most commonly with dorsal contracture of the second toe and medial drift over the Hallux. In this article, the authors present a comprehensive stepwise approach to diagnosing and treating plantar plate injuries using both dorsal and plantar approach techniques.

Lapidus Arthrodesis.

There has been significant enhancement in surgical management of hallux valgus deformity. Recognition of the role of medial column hypermobility has resulted in better functional outcomes with decreased risk of recurrence. Modern techniques have evolved to include enhanced fixation in a move toward minimal postoperative downtime. Evolution to include true triplane correction, including frontal plane derotation of the first ray, has resulted in optimal functional outcomes. The addition of anatomic triplane restoration, enhanced internal fixation, and early return to weight-bearing activities are combined resulting in lifelong correction with excellent functional outcomes and a high degree of patient satisfaction.

Current Techniques in Total Ankle Arthroplasty.

Total ankle replacement (TAR) continues to increase in popularity as a motion-preserving option to ankle arthrodesis. TAR is indicated for primary, posttraumatic and inflammatory arthropathies as an alternative procedure to tibiotalar arthrodesis. Proper patient selection is paramount to a successful outcome in TAR. Contraindications to TAR include the presence of neuropathy, active infection, severe peripheral arterial disease, inadequate bone stock, and severe uncorrectable coronal plane deformity. This article is a brief overview of techniques and PEARLS on how to address a well-aligned ankle joint, varus deformity as well as valgus deformities as well as the authors' experience with single versus staging coronal plane deformities.

Neglected Achilles Tendon Ruptures.

Achilles tendon ruptures are a common ailment and often missed in upwards of 25% of cases. Neglected Achilles injuries can be treated both conservatively and surgically. Physical therapy, bracing, and custom ankle-foot orthoses are some options to consider. Surgically, there are many options, depending on the quality of the existing tendon, size of the defect, and the surgeon's comfort with the technique. Those procedures include primary repair, V-Y tendon advancement, turndown flap, tendon transfers, and other allografts. These techniques have been shown to have good to excellent outcomes and typically return patients to activities without complaints.

Treatment of Lisfranc Injuries Using Interosseous Suture Button: A Retrospective Review of 84 Cases With a Minimum 3-Year Follow-Up.

Lisfranc fracture dislocation is an injury often encountered by the foot and ankle surgeon. This injury, depending on the severity and level of energy, has been shown to lead to posttraumatic osteoarthritis and chronic pain if undiagnosed or improperly managed. The purpose of this study was to retrospectively evaluate the surgical repair with the use of an interosseous suture button for Lisfranc injuries with isolated ligamentous disruption. From 2008 through 2016, 104 patients were consecutively enrolled who underwent open reduction internal fixation (ORIF) of the Lisfranc complex with a suture button and stabilization of the medial and intermediate cuneiform with a 4.0-mm screw. Eighty-four patients were available for a 3-year minimum follow-up. The mean return to full weightbearing was 11 days protected in a controlled ankle motion (CAM) boot. American Orthopedic Foot & Ankle Society (AOFAS) and visual analog scale (VAS) scores improved from 30 and 8.4, respectfully, preoperatively to 90 and 1.3 postoperatively. The mean preoperative step-off between the second metatarsal base and intermediate cuneiform was found to be 3.15 mm. The immediate postreduction weightbearing radiograph measured 0.25 mm and 0.43 mm at the final follow-up evaluation, a difference that was found to be significant. There were no revision arthrodeses performed and no removal of the suture button during this time period. ORIF using an interosseous suture button appears to have an adequate medium-term patient satisfaction; however, there is evidence of minimal diastasis in some patients at 3 years postoperatively in ligamentous Lisfranc fracture dislocations.

Evaluation of BMI With an All Inside Arthroscopic Broström Procedure for Chronic Lateral Ankle Instability: An Analysis of 113 Patients.

The all inside arthroscopic Broström surgical procedure for chronic lateral ankle instability is a minimally invasive procedure that is an option surgeons have when treating their patients. There have not been any studies analyzing the integrity of the repair to patients who have an elevated body mass index (BMI) to determine if the strength of the repair is adequate. We retrospectively evaluated a total of 113 consecutive patients who underwent this procedure. Fifty-nine patients had a BMI ≥30 kg/m2; 54 had a BMI <30 kg/m2. Unpaired t tests were performed to determine if a difference in American Orthopedic Foot and Ankle Society, visual analog scale, and Foot Function Index were encountered. Our findings indicate that there is no significant difference between patients with a BMI ≥30 kg/m2 compared to a BMI <30 kg/m2 who undergo an all-inside arthroscopic Broström procedure for chronic lateral ankle instability. This information may help surgeons decide what procedure options are available when treating chronic lateral ankle instability.

Age-Related Outcomes in Total Ankle Arthroplasty: An Analysis of 112 Patients.

Traditionally, total ankle replacement has been reserved for elderly patients with low physical demands. With nearly 80% of end-stage ankle arthritis being secondary to prior trauma, patients may require a replacement at a much younger rate than primary hip and knee arthritis. Historical accounts of implant failure and high revision rates in younger patients have been reported in the literature. With increasing technology and surgeon experience, implants are being used in younger patients with significantly fewer complications than early reports. In this retrospective review, we evaluated the patient-reported outcome measures and implant complications in three age subsets in arthroplasty patients; Group 1: <55 years-old, Group 2: 55-70 years-old, and Group 3: >70 years-old. In our study, mean postoperative American Orthopedic Foot and Ankle Society (AOFAS) hindfoot scores were 75.5 for group 1, 79.7 for group 2, and 86.9 for group 3, which improved from preoperative scores of 50, 52.4, and 53.8, respectively. Mean postoperative Foot Function Index (FFI) scores were 10 for group 1, 23.9 for group 2, and 12.3 for group 3, which improved from 59.4, 62.8, and 47.6 preoperatively, respectively. The overall complication rate was found to be 11.2%. The complication rate for group 1 was 18%, the complication rate for group 2 was 11.6%, and the complication rate was 9.4% for group 3. The differences in patient AOFAS hindfoot, FFI scores, and complication rates between the groups were not found to be statistically significant. Our results show that patients younger than age 55 years have similar complication rates and reported satisfaction scores to patients 55 years of age and older.

The Effect of Tobacco Use on Incision Healing in Total Ankle Arthroplasty: A Review of 114 Patients.

The purpose of this study was to compare wound complication rates after total ankle replacement in 3 groups of patients based on tobacco status. The total cohort was divided into 3 groups based on tobacco history. Group 1 included patients who were actively tobacco users. Group 2 included patients with a history of tobacco user. Group 3 served as the control group and included patients who had never used tobacco. Available charts were reviewed for patients who underwent primary total ankle arthroplasty by 1 surgeon. Patient demographics, tobacco history, and postoperative wound complications were recorded. A total of 114 patients with tobacco history were available for follow-up and were included in this study, which ranged from March 2012 to July 2017. Group 1 included 11 active smokers. Group 2 included 38 former smokers, and group 3 had a total of 65 never smokers included. The average follow-up was 28 months for group 1 (range 10-55 months), 34.1 months for group 2 (range 12-60 months), and 32.8 months for group 3 (range 11-60 months). The wound complication rate was noted to be statistically significant when comparing active smokers to never smokers using Fisher's exact test (P = .0223). When comparing former smokers with never smokers, the difference in wound complication rate did not reach statistical significance (P = 0.7631). All patients underwent at least 1 concomitant procedure at the time of initial ankle replacement. Our findings show that total ankle replacement wound healing complication rates are significantly higher in active tobacco users. There was no significant difference in wound healing complications when comparing former tobacco users versus never tobacco users. Levels of Evidence: Level III: Retrospective comparative study.

Relationship Between Body Mass Index and Complications in Total Ankle Arthroplasty: A Single Surgeon's Experience in Ninety-Seven Replacements.

The purpose of this study was to compare complication rates of total ankle replacement in 2 groups of patients based on their body mass index (BMI). The total cohort was divided into 2 groups based on BMI. Group 1 included patients with a BMI ≤30 kg/m2. Group 2 included patients with a BMI >30 kg/m2. Available charts were reviewed for patients who underwent primary total ankle arthroplasty. Patient demographics, BMI, prosthesis used, concomitant procedures, and intraoperative and postoperative complications were recorded. Ninety-seven patients met the inclusion criteria and underwent total ankle replacement between March 2012 and July 2016. Mean follow-up was 26.3 (range 12 to 62) months. Mean age was 66.4 (range 23 to 85) years. Mean BMI was 29.6 (range 20.6 to 49.5) kg/m2. Forty-three males and 54 females were included. There were 53 patients in group 1 (BMI ≤30 kg/m2) and 44 patients in group 2 (BMI >30 kg/m2). Total complication rates for group 1 and 2 were 18.9% (10 of 53) and 11.4% (5 of 44), respectively. There were a total of 10 minor complications and 5 major complications. There was no statistical difference between the groups (p = .308) in terms of complication rates. All patients underwent at least 1 concomitant procedure at the time of the index ankle replacement. We found that total ankle replacement can be safely utilized in patients with a BMI >30 kg/m2. In the present study, there was no statistical significance in complication rates in the 2 groups.

Intraoperative Reduction Techniques for Surgical Management of Displaced Intra-Articular Calcaneal Fractures.

Fractures of the calcaneus are detrimental injuries, often caused by high-energy trauma. To best restore the functionality of a limb and allow normal ambulation, it is recommended to repair displaced intra-articular calcaneus fractures surgically. This article presents several methods of reduction and repair of the calcaneus. Traditionally, calcaneal fractures have been repaired through a lateral extensile incision that has been shown to have a high percentage of wound healing complications. In recent times, there has been a shift toward minimally invasive and sinus tarsi incisional approaches in the repair of calcaneus fractures.

A comparison of the "All-Inside" arthroscopic Broström procedure with the traditional open modified Broström-Gould technique: A review of 62 patients.

BACKGROUND: The open Broström-Gould lateral ankle stabilization procedure has been the gold standard for primary lateral ankle stabilization. A new minimally invasive all-inside arthroscopic technique has been described for the correction of lateral ankle instability. METHODS: We performed a review of patients who underwent lateral ankle stabilization by either the traditional open Broström-Gould (BG) or the All-Inside Bröstrom (AIB) technique to compare and identify any discrepancies between functional and/or patient satisfaction outcomes. A total of 62 patients underwent a lateral ankle stabilization. Of those 62 patients, 32 received a traditional open Broström-Gould procedure and 30 patients underwent an All-Inside Bröstrom type procedure. The two groups were compared preoperatively with AOFAS ankle-hindfoot scoring system and Visual Analog Score (VAS) for pain. Postoperatively, AOFAS, Karlsson Peterson and VAS scores were compared. RESULTS: The mean preoperative VAS pain score for the open Broström-Gould was 7.28, the All-Inside Broström was 8.18. The mean postoperative VAS pain score for the open Broström-Gould was 1.2, the All-Inside Broström was 1.5. The mean preoperative AOFAS score for the Broström-Gould was 35.44, the All-Inside Broström was 35.07. The mean postoperative AOFAS score for the open Broström-Gould was 93.53, the All-Inside Broström was 95.33. The mean postoperative Karlsson Peterson score for the open Broström-Gould was 93.41, the All-Inside Broström was 91.80. The mean time to weight bearing for the Broström-Gould was 22 days, the All-Inside Broström was 12 days. CONCLUSION: There were no statistically significant differences identified in any of the functional or patient satisfaction outcome scores using either technique. This review suggests the minimally invasive arthroscopic technique using bone anchors for lateral ankle stabilization may be comparable to the traditional open Broström-Gould with the added advantage of earlier time to weight bearing.

The Relationship Between Polyethylene Insert Size and Complications in Total Ankle Replacement.

The purpose of this study was to compare complication rates after total ankle replacement in 2 groups of patients based on polyethylene insert size. The total cohort was divided into 2 groups based on insert size. Group 1 included patients with polyethylene insert size less than 10 mm in thickness. Group 2 included patients with polyethylene insert sizes 10 mm and larger. Available charts were reviewed for patients who underwent primary total ankle arthroplasty by one surgeon. Patient demographics, polyethylene insert size, implant used, concomitant procedures, postoperative complications, and patient-reported outcome scores were recorded. One hundred patients were available for follow-up and were included in this study, which ranged from March 2012 to July 2017. The average follow-up was 31.3 months (range = 10-60 months). Forty-eight females and 52 males were included in this study. There were a total of 63 patients in group 1 and 47 patients in group 2. The total complication rate for patients in group 1 was 11.1% (7/63), and in group 2 it was 16.2% (6/32). There was no statistical significance in complication rates when comparing the 2 groups (P = 0.5427). All patients underwent at least one concomitant procedure at the time of initial ankle replacement. Our findings show that total ankle replacement complication rates are equal when comparing large polyethylene inserts commonly utilized to correct deformities, versus small polyethylene inserts commonly utilized in primary resurfacing. Levels of Evidence: Level IV, Retrospective comparative study.