Maintenance of Correction of the Modified Lapidus Procedure With a First Metatarsal to Second Metatarsal Screw With "Spot Weld" Technique: A Retrospective and Radiographic Analysis.

Lapidus first tarsometatarsal (TMT) arthrodesis gained popularity for its ability to correct large deformities especially in cases of medial column instability. Despite solid first TMT fusion, instability between the first and second columns can result in loss of intermetatarsal (IM) angle correction over time. A "spot weld" or fusion between the first and second metatarsal may improve maintenance of correction. This retrospective study reviewed cases of Lapidus arthrodesis with first to second metatarsal base screw fixation for maintenance of IM correction and determine whether a "spot weld" is predictive of maintenance. A total of 90 cases (77 patients) performed by a single surgeon met inclusion with average follow-up of 309 days. First TMT fusion occurred in 87/90 (96.7%) cases with 76 dorsal plate, 10 dorsal staple, and 4 all screws. No incidence of complications related to the 1-2 screw was noted. Mean preoperative IM 1-2 angle 14.90°, mean correction to 6.22° post-operative and final maintained correction at 7.10°, mean loss of correction 0.87°. There were "spot welds" in 65/90 (72.2%) with mean loss of 0.48° versus loss of 1.88° in "no spot weld" subgroup (p < .001). Cases with no spot weld and screw lucency lost 2.25° (p < .001). Loss of IM 1-2 correction can occur due to first and second ray intra-column instability even in cases of solid first TMT arthrodesis. Incorporating a completed "spot weld" with bone grafting and first to second metatarsal screw was found to maintain correction with minimal loss (0.87°).

A Study of Tibial Cyst Formation in Modular Stemmed Total Ankle Arthroplasty: Exploring a Possible Relationship to Smooth and Porous Coating on the Stem Segments.

Vertical fixation through stemmed components has been a successful strategy in total ankle arthroplasty. Research in hip replacement surgery has demonstrated increased rates of stress shielding, aseptic loosening, thigh pain, and cystic formation around stemmed femoral implants extensively coated with porous surfaces. While some ankle prostheses have integrated porous coating technology with stemmed tibial implants, there is little to no research investigating the potential negative effects of bone bonding to the tibial stems and possible impact on tibial cyst formation. We performed a retrospective cohort study comparing the incidence of periprosthetic tibial cyst formation in smooth versus fully porous-coated stemmed tibial implants after undergoing total ankle implant arthroplasty. Radiographs were compared for postoperative rates of tibial cyst formation and bone bonding to the tibial stems. Relative risk for reoperation between the smooth and porous-coated implants was investigated. The smooth-stem group showed no incidence of tibial cyst formation nor signs of significant bone bonding to the tibial stems; however, the follow-up matched porous-coated group showed a rate of 63% of cystic formation with associated evidence of bone bonding on final radiographic follow-up (p < .01). Relative risk for reoperation was 0.74. Despite a higher incidence of tibial cyst formation in the stemmed ankle arthroplasty groups with porous coating, reoperation rates were similar. We theorize that the proximal bonding to the porous stem surface could impact the distal stems and result in the observed increase in cyst formation.

Comparison of Dynamic Versus Static Locked Retrograde Tibiotalocalcaneal Arthrodesis With Intramedullary Nail Fixation: Evaluation of the RAIN Database.

Hindfoot osteoarthritis (OA) or deformity involving the ankle and subtalar joint is a disabling condition. Tibiotalocalcaneal (TTC) fusion is an effective salvage option in pathologies where total ankle replacement is contraindicated. The purpose of this study is to compare the union rate of the ankle joint in proximal static versus dynamically locked retrograde intramedullary nail fixation for tibiotalocalcaneal arthrodesis. An institutional review board-approved comprehensive chart and radiographic review was performed. TTC arthrodesis performed in patients with OA, post-traumatic arthritis, or deformity corrected by retrograde nail were included. Patients with Charcot arthropathy, failed joint replacement, neuropathy, or avascular necrosis were excluded. The primary outcome was ankle joint union with secondary measure of mean time to fusion. A total of 60 patients met inclusion criteria with 30 in the static group (SG) and 30 in the dynamic group (DG). The average age of the static group (SG) and dynamic group (DG) was 56.9 and 54.1 years, respectively. Mean body mass index was 34.03 kg/m2 for SG and 33.43 kg/m2 for DG. The union rate of the ankle joint was slightly higher in the DG but not statistically significant [SG 83.3%, DG 86.6%, p > .05 (p = .83)]. Time to fusion (TTF) in SG was 111.6 days compared to 97.2 days in DG. Dynamically locked intramedullary nails allow continued compression across the arthrodesis site as fusions remodel. Time to union and union rate of the ankle joint was superior in the dynamic group but this was not statistically significant. In this cohort, union rates were excellent in both groups, and no statistically significant difference was seen in the number of nonunions.

Direct Plantar Approach to Plantar Plate Repair and Associated Wound Complications.

BACKGROUND: Lesser toe metatarsophalangeal joint (MTPJ) instability, secondary to plantar plate tear, has been the focus of numerous recent publications, the majority reporting on repair through a dorsal approach. A plantar approach has been described with the advantage of direct ligamentous repair or repair to bone, which follows conventional techniques employed throughout the body. Previous clinical studies have shown success in deformity correction and the longevity of both approaches. The proponents of the dorsal approach advocate that indirect repair of the plantar plate avoids perceived risks of complications with a plantar incision without evidence of superior outcomes. The purpose of this study was to investigate the safety and efficacy of the direct plantar approach to plantar plate repairs (PPRs) by reporting the rate of specific complications in a large clinical series. METHODS: This was the institutional review board (IRB) approved retrospective study of 204 PPRs in 185 patients (194 lesser MTP, 10 hallux MTP) with an average age of 56 and a mean body mass index (BMI) of 28. Surgical technique involved repair with absorbable braided suture (88%) versus suture anchor (12%) with or without MTPJ pinning (80%). Mean follow up was 53 weeks (range 5-170). Patients were screened for associated risk factors, including diabetes mellitus (8%), tobacco use (5%), neuropathy (1%), and additional concurrent procedures (96%). Complications were defined as superficial or deep infection, painful scars, and reoperation. Analysis was conducted using the Wilcoxon-Mann-Whitney test or Fisher's exact tests for continuous and categorical variables, respectively. Risk factors were analyzed using univariate logistic analysis to produce odds ratios (OR) with a 95% confidence interval (CI) and an inclusion criterion of a P-value, P > .2 for multivariate analysis as determined by Wald tests (significance at P < .05 for final modeling). RESULTS: Overall, there were 31 total complications (15%) demonstrated by 14 superficial infections (6.8%) and 17 painful scars (8.3%) along with three reoperations (1.4%). All reoperations were performed for deformity or instability, not scar revision. There were no deep infections. No increased odds of complications were found with suture anchor repair, MTPJ pinning, neuropathy, or diabetes. Patients that used tobacco had 7.5 (CI 1.66, 34.06) the odds of developing any wound complication compared with nonsmokers. Tobacco use was also found to significantly increase the odds of superficial infection by 9.8 (CI 2.08, 46.15). There was no increase in painful scars or reoperation in tobacco users. This study did not find an increased complication rate with additional ipsilateral procedures performed at the time of surgery. CONCLUSION: To our knowledge, this is the largest study evaluating the direct plantar approach to PPR as well as the evaluation of associated complications with the plantar incision. With low complication and minimal reoperation rates, the results of this study have demonstrated the clinical viability of plantar-based incisions. Previous studies have demonstrated the success of PPR and correction of deformity with a direct approach. This case series further demonstrates the safety and efficacy of plantar-based incisions, particularly for direct PPRs. LEVEL OF EVIDENCE: IV Retrospective Case Series. CATEGORY: Lesser Toes.

Incidence of Scholarly Publication by Selected Content Experts Presenting at National Society Foot and Ankle Meetings From 2016 to 2020.

Continuing medical education (CME) is an important element to maintain licensing requirements, enhance professional competence, and disseminate up to date, evidence-based, treatment recommendations. A key resource of CME are the 2 annual society meetings hosted by the American College of Foot and Ankle Surgeons (ACFAS) and American Orthopedic Foot and Ankle Society (AOFAS). It is assumed that the selected speakers at these meetings are content experts, providing validated expertise on treatment recommendations, rather than anecdotal experience or opinion. Across all medical specialists, peer-reviewed publication(s) on a particular subject matter have long bestowed the ultimate validity of "expertise." The purpose of this study was to assess the incidence of scholarly publication for invited speakers at the ACFAS and AOFAS annual meetings from 2016 to 2020, in relation to the topic they were selected to present. A review of invited lectures given at the ACFAS and AOFAS annual meetings from 2016 to 2020 was conducted, and lecturer demographics were categorized into predetermined content areas for assessment. Selected speakers were individually cross-referenced with content-specific peer-reviewed published literature, and overall h-index using Scopus. Topic and society specific comparisons were then made. Overall, 1028 lectures were identified during the temporal period. Only 300 (29.18%) presentations were given by a speaker with least one or more publication on the society specific lecture-topic presented. The greatest proportion of lecturers with content-specific publications was Charcot reconstruction (67.57%) followed by ankle fusion/replacement (55%). The average presenter h-index was greatest among total ankle replacement/ankle fusion (12.16 ± 6.90) and Charcot reconstruction (11.27 ± 7.10) content. The results of the present study illustrate a disparity of expertise among different content areas. While both meetings provide well-published lecturers, this study reveals areas for improvement.

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.

High Utility of the 1st Metatarsal Phalangeal Joint Fusion.

Fusion of the first metatarsophalangeal joint has been used by foot and ankle surgeons as a reproducible and useful means of treating end-stage arthritis of the great toe. However, the overall utility and successful outcomes of this procedure have led to its incorporation into the treatment of more significant bunion deformities, reconstruction forefoot, and salvage procedures. The authors review surgical fixation methods, offer insightful technical pearls for challenging cases and share examples of complex reconstructive and salvage procedures.

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.

Soft Tissue Reconstruction and Osteotomies for Pes Planovalgus Correction.

The correction of the flexible pes planovalgus foot and ankle is a complicated and somewhat controversial topic. After conservative methods fail, there is a wide range of possible soft tissue and bony procedures. The appropriate work up and understanding of the pathomechanics are vital to the correct choice of procedures to correct these deformities. Once the work up and procedure selection are done, the operation must also be technically performed well and with efficiency, as most often the condition is corrected with a variety of procedures. This article discusses some of the most common procedures necessary to fully correct the pes planovalgus foot and discusses the authors' technique and pearls.

Deformity Correction of the Midfoot/Hindfoot/Ankle.

The correction of the deformed arthritic foot and ankle is a complicated and somewhat controversial topic. After conservative methods fail, there is a wide range of possible bony procedures and arthrodesis that maybe performed. The appropriate work up and understanding of the pathomechanics is vital to the correct choice of procedures to correct these deformities. Once the work up and procedure selection is done, the operation must also be technically performed well and with efficiency, as most often the condition is corrected with a variety of procedures. This article discusses some of the most common procedures necessary to fully correct deformity of the midfoot, hindfoot, and ankle. This article will also discuss the authors' technique and pearls.

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.

Post-Fellowship Foot and Ankle Surgeon Research Productivity: A Systematic Review.

Though foot and ankle surgery fellowships have been around for decades, contributing factors for long-term research productivity remain unreported. Along with enhancing surgical training, the American College of Foot and Ankle Surgeons (ACFAS) tasked programs with fostering research in effort to continue post-fellowship investigations. As the number of fellowship programs and fellows continues to increase, this study attempts to identifies factors associated with postfellowship research success. A PubMed search of peer-reviewed literature authored by ACFAS recognized 1-year fellowship graduates from 2000-2018 was conducted. Demographic data including current practice type and location was collected. Research activity at the 3, 5, and 10-year postfellowship period was investigated between publication history and current practice type. Statistical significance was set at p ≤ .05. Among the 37 fellowships assessed, 132 fellows were eligible for analysis. Most fellows maintained hospital-based employment 46 (34%) followed by private 44 (33%) and orthopedic group 30 (22%) practices. The proportion of fellows that published 5 and 10 years postfellowship was associated with research productivity 3 and 5 years postfellowship (p ≤ .03). The odds of publishing 3 years post-fellowship in orthopedic groups and university-based practices were 1.62 and 4.42 times higher compared to hospital-based graduates, respectively. The odds of publishing 5 years post-fellowship in orthopedic group and university based practices were 3.5 and 6.63 times higher than hospital-based practices, respectively. Despite the growing number of fellowships, a small proportion of fellows continue publishing postfellowship. These findings support the need to provide resources to engage graduates if retaining young practitioners in scholarly activity is desired.

Heterotopic Ossification Following Total Ankle Arthroplasty With Fourth-Generation Prostheses.

BACKGROUND: The purpose of the present study was to assess the radiographic incidence, location, and classification of heterotopic ossification (HO) in patients who underwent total ankle arthroplasty (TAA) with a 4th generation prostheses at a minimum of 1-year follow up. Baseline demographic, radiographic, and operative factors between patents with and without HO were compared. METHODS: Ninety ankles that underwent TAA with a 4th generation protheses, INFINITY (n = 62) or CADENCE (n = 28) were followed for an average of 23.7 (range, 12-49) months. Incidence and location of HO was assessed on weightbearing radiographs, and severity graded according to the modified Brooker classification. Data was compared between patents with and without HO to identity any predisposing factors. RESULTS: In 90 ankles that underwent 4th generation TAA, HO incidence was 55.6% (n = 50); 56.5% (n = 35) for INFINITY, and 53.6% (n = 15) for CADENCE. Twenty-five cases of HO were observed posteriorly, 16 anteriorly, and 9 combined. Severity was as follows; class I in 19 cases (38%), class II in 20 (40%), class III in 9 (18%) and class IV in 2 (4%). A single ankle required a non-revisional reoperation for HO debridement; reoperation rate of 2%. CONCLUSION: The present study suggests a similarly high incidence of HO after TAA with two different 4th generation protheses (INFINITY 56.5%, CADENCE 53.6%). A trend for differences in location and severity between the protheses may also be present. Given the paucity of literature, additional studies with longer follow-up are warranted to discern the significance of HO following TAA with 4th generation protheses. LEVEL OF EVIDENCE: Level III: Retrospective cohort study.

The INFINITY Total Ankle Prosthesis: Outcomes at Short-Term Follow-up.

BACKGROUND: The INFINITY total ankle prothesis remains the most widely used fourth-generation total ankle arthroplasty (TAA) system in the United States. The purpose of the present study was to assess radiographic outcomes for INFINITY at short-term follow-up. METHODS: All patients who underwent primary TAA with INFINITY between August 2015 and June 2018 at a single institution and who were at least 1 year postoperative were included. A total of 55 ankles with a mean follow up 22 months (range, 12-43 months) met the criteria. Weightbearing radiographs were assessed using coronal and sagittal alignment parameters preoperatively, at 6 to 8 weeks postoperatively, and at the most recent follow-up. Medical records and charts were reviewed and revisions, reoperations, and complications were classified according to the criteria established by Vander Griend et al and Glazebrook at el, respectively. RESULTS: Overall, INFINITY survivorship was 98.2%. Coronal and sagittal tibiotalar alignment improved after surgery (P < .001, P = .09, respectively), and was maintained during the latest follow-up (P = .62, P = .47, respectively). Only 1 ankle (1.8%) required early revision; while 5 (9.1%) indicated non-implant-related revision; 85.5% required no reoperation. In nineteen ankles (34.5%), postoperative periprosthetic lucency was observed; most were not progressive (17 ankles, 89.5%). Twelve complications (3 high grade, 3 intermediate, and 6 low grade) in 11 ankles (20%) were recorded according to the Glazebrook classification system. CONCLUSION: INFINITY survivorship was 98.2% at a mean of 1.8 years of follow-up, and only 1 ankle required prosthetic revision. Additional studies with longer follow-up are warranted for fourth-generation TAA prostheses. LEVELS OF EVIDENCE: Level IV: Case series.

Total Ankle Arthroplasty Survivorship, Complication, and Revision Rates in Patients Younger Than 55 Years.

Total ankle replacement has become a viable alternative to ankle arthrodesis in the surgical management of advanced ankle arthritis. Total ankle replacement has generally been reserved for patients who are older and for those who will have a lower demand on the replacement. The purpose of the current study is to review patient outcomes, complications, and implant survival in patients younger than 55 years who underwent total ankle replacement at a single institution. A single-center chart and radiographic review was performed of consecutive patients who underwent total ankle replacement for treatment of end-stage ankle arthritis. All surgeries were performed by 1 of 5 fellowship-trained foot and ankle surgeons at a single institution. A total of 51 patients met inclusion criteria with a mean follow-up of 31.2 months (SD = 16.2). Implant survival was 94%, There were 7 major complications (13%) requiring an unplanned return to the operating room and 8 minor complications (15%) that resolved with conservative care. The results of this study show that total ankle replacement is a viable treatment option for patients younger than 55 years.Levels of Evidence: A retrospective case series.

The Safety Profile of Same-Day Outpatient Total Ankle Arthroplasty.

There has been significant change in the health care policy in the United States in recent years with an increasing focus on health care costs and patient satisfaction. One strategy of cost containment is to transition outpatient surgery away from high cost hospital environments. Total ankle arthroplasty has begun the evolution to outpatient settings; however, there is limited published literature on the results of outpatient total ankle arthroplasty (TAA). The purpose of the present study was to review the safety profile of same day outpatient TAA at an ambulatory surgery center. A review of consecutive patients who underwent same day outpatient TAA for end-stage ankle arthritis with a minimum of 12 months' follow-up was performed. The primary outcomes assessed were the incidence of perioperative adverse medical events, hospital admissions related to the procedure, and postoperative complications (minor and major). Univariate analyses were performed. Fifty-one patients who underwent same-day TAA between June 2016 and July 2018 were included; mean follow-up was 20.7 months (± 7.6). The mean age at time of surgery was 56.5 years (± 7.2), with a mean body mass index of 30.4 (± 5.3). Overall, there were no perioperative adverse medical events or hospital admissions related to the procedure. Five minor complications (9.8%) and 7 major (13.7%) were recorded. Of the major complications, only 1 required TAA revision. Implant survivorship during the most recent follow-up was 98%. The present study suggests that TAA can be performed safely in an outpatient ambulatory setting. Additional comparative studies with larger TAA cohorts and patient reported outcomes are warranted.

A Comparison of Complications and Reoperations Between Open Reduction and Internal Fixation Versus Primary Arthrodesis Following Lisfranc Injury.

There is a lack of consensus in the literature regarding optimal treatment methods for Lisfranc injuries, and recent literature has emphasized the need to compare open reduction and internal fixation (ORIF) with primary arthrodesis (PA). The purpose of the current study is to compare reoperation and complication rates between ORIF and PA following Lisfranc injury in a private, outpatient, orthopaedic practice. A retrospective chart review was performed on patients undergoing operative intervention for Lisfranc injury between January 2009 and September 2015. A total of 196 patients met the inclusion criteria (130 ORIF, 66 PA), with a mean follow-up of 61.3 and 81.7 weeks, respectively. The ORIF group had a higher reoperation rate than the PA group, due to hardware removal. When hardware removals were excluded, the reoperation rate was similar. Postsurgical complications were compared between the 2 groups with no significant difference. In conclusion, ORIF and PA had similar complication rates. When hardware removals were excluded, the reoperation rates were similar, although hardware removals were more common in the ORIF group compared with the PA group.Levels of Evidence: Level III.

Research Activity Among Foot and Ankle Surgery Fellows: A Systematic Review.

Surgical residents cite a number of reasons to pursue a fellowship training program including improving surgical skills, furthering medical research, pursuing an academic practice, or to generally become an overall better trained surgeon and clinician. The interest in foot and ankle surgery fellowships has increased among graduating residents as have the number of fellowship programs. Since the introduction of these programs, there has been no formal investigation of the scholarly activity among foot and ankle surgery fellows. Using PubMed, a systematic review was conducted from papers published by fellows participating in American College of Foot and Ankle Surgeons or American Podiatric Medical Association approved fellowships during 2013 to 2019. A total of 76 of the 128 identified fellows published research during or within one year of completing their fellowship. Fellows that published at least once prior to fellowship were more likely to publish during fellowship compared to those who had no publication history. Over this 6-year period, fellows contributed to 279 manuscripts where they maintained primary authorship of 34.41% of the publications, across 35 journals, with the most common being the Journal of Foot and Ankle Surgery. Results of this study provide a survey of the scholastic activity among foot and ankle surgery fellows and could be used by applicants and evaluators to stratify applicant aptitude. These results could also serve as a scholarly activity benchmark for current fellows and a method of gauging scholarly involvement for new and current fellowships.

Does Functional Neuromuscular Electrical Stimulation (NMES) Influence Calf Atrophy Following Achilles Tendon Surgery? Prospective Double-Blind Randomized Controlled Trial on the Use of Immediate Postoperative Electrical Muscle Stimulation to Preserve Muscle Function and Volume.

Surgical repair of the Achilles tendon can lead to prolonged calf atrophy and functional limitations, even with early weightbearing. The use of neuromuscular electrical stimulation (NMES) has been studied in muscle rehabilitation programs following anterior cruciate ligament repair. Accelerated recovery and pain reduction were noted. The aim of the present study was to evaluate the use of electrical stimulation on maintaining calf muscle cross-sectional area volume and improving patient reported outcome measures following Achilles tendon surgery. Randomized controlled clinical trial. Forty patients were enrolled. All patients had undergone repair of the Achilles tendon. A 4 lead NMES device was applied at time of surgery with both patient and surgeon blinded to activity of the device. All patients followed a standardized postoperative protocol. Group 1 consisted of 20 patients who received protocol specific NMES. Group 2 was the "sham device" control group, receiving subtherapeutic electrical stimulation. Preoperative and postoperative calf circumference (2, 6, 12 weeks) and magnetic resonance imaging (MRI) scans (2, 6 weeks) were conducted. Patient-reported functional outcome scores were measured. Of the 40 patients, 23 (57.5%) were male and 17 (42.5%) were female. The mean age was 48.9 years (11.1 standard deviation [SD]) with a mean body mass index of 32.2 kg/m2 (5.7 SD). Calf measurements for Group 1 (39.3 cm and 39.7 cm) were slightly higher compared Group 2 (38.4 cm and 39.2 cm) at 6 and 12 weeks postoperative. Functional scores were similar between Groups 1 and 2 at final follow-up. Foot/Ankle Computer Adaptive Test scores were 55.1 (6.9 SD) versus 58.4(8.6 SD), and American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scores were 82.3 (8.2 SD) and 83.9 (9.3 SD), respectively. The visual analog scale at 12-week visit for Groups 1 and 2 was 8.4 (9.3 SD) and 8.4 (9.1 SD), respectively. This prospective randomized controlled trial was undertaken to quantify and validate the effect and ability of NMES to minimize calf atrophy after acute or chronic repair. No statistically significant difference was found between active NMES and sham control group. There was a trend showing some maintenance of calf volume per MRI study.