Takedown of Ankle Fusions and Conversion to Total Ankle Replacements.

BACKGROUND: With ankle replacements gaining credibility, there is a small subset of patients who might benefit from a conversion of an ankle fusion to a replacement. The objective of this study is to present clinical and radiographic results of patients who had their ankle fusion converted to total ankle arthroplasty (TAA). METHODS: Patients presented to the senior author with ongoing ankle pain following fusion or increasing pain after a period of relative comfort after an ankle fusion. Outcomes were evaluated preoperatively and postoperatively with the Veterans Rand Health Survey (VR-12), Ankle Osteoarthritis Scale (AOS), and visual analog scale (VAS) pain scale. A patient satisfaction survey was also distributed. RESULTS: All ankle fusion conversions between April 2010 and December 2019 were included. Fifty-one patients (30 females) with the mean age of 62.6 (range, 37-83) years were followed. Mean follow-up was 4.2±2.3 (range, 2-11.5) years. Two patients were lost to follow-up (1 is deceased). Pre- and postoperative mean patient-reported outcome scores were all significantly different between groups except VR-12 mental subscale scores. VR-12 physical scores improved from 28.7±8.9 preoperatively to 38.9±9.9 (P < .001) postoperatively; VR-12 mental score was stable. AOS pain and disability subscales similarly improved: 55.9±24.4 to 27.9±25.4 (P < .001) and 61.7±21.1 to 31.1±25.7 (P < .001), respectively. VAS pain improved from a mean of 64.5±27.3 to 29.4±27.7 (P < .001). There was no tibiotalar dorsiflexion or plantarflexion with the ankle fusion. Initial postoperative visit revealed that average dorsiflexion was 10.9±5.93 degrees and average plantarflexion was 14.1±5.22 degrees. At the latest follow-up, dorsiflexion improved significantly to 15.5±6.33 degrees (P < .001), with no significant improvement in plantarflexion (P = .980). CONCLUSION: In this single-surgeon longitudinal study of 51 patients with a painful, malaligned, or nonhealed ankle fusion treated with an ankle replacement, we found highly satisfactory functional outcomes at an average of 4.2 years. Continued long-term follow-up will reveal whether the longevity of these replacements is comparable to primary replacements.

Plantar plate radiofrequency and Weil osteotomy for subtle metatarsophalangeal joint instablity.

BACKGROUND: To the present day, literature has only discussed how to treat extensive plantar plate and collateral ligament lesions, with gross joint subluxation and obvious clinical instability. The treatment options for early stages of the disease with minor injuries and subtle instabilities have not been described. The main purpose of this prospective study is to evaluate the efficacy of the combination of the arthroscopic radiofrequency shrinkage and distal Weil osteotomy in the treatment of subtle metatarsophalangeal joint instability. METHOD: Prospective data (clinical, radiological, and arthroscopic findings) of 19 patients, with a total of 35 slightly unstable joints, was collected. The physical examination defined the hypothesis for plantar plate lesions (grades 0 and 1), which was confirmed during the diagnostic step of the arthroscopic procedure. RESULTS: Among our patients, 73% were females and 63% reported wearing high heels. The average age was 59 years and post-operative follow-up was 20 months. In the initial sample frame, 62% of joints showed spread-out toes with increased interdigital spacing. The mean American Orthopedic Foot and Ankle Society score rose from 53 points pre-operatively to 92 points post-operatively and a visual-analog pain scale average value of eight points pre-operatively decreased to zero post-operatively. During the pre-operative evaluation, none of the patients had stable joints and over 97% were classified as having grade 1 instability (<50% subluxation). After treatment, 83% of the joints became stable (degree of instability 0) and over 97% were congruent. All studied parameters showed statistically significant improvements in the post-operative period (p < 0.001) showing the efficiency of the treatment in pain relief, while restoring the joint stability and congruity. CONCLUSION: Arthroscopic radiofrequency shrinkage in combination with distal Weil osteotomy promotes functional improvement, pain relief, and restores the joint stability in the plantar plate lesion grades 0 and 1.

Shoe heel abrasion and its possible biomechanical cause: a transversal study with infantry recruits.

BACKGROUND: Excessive shoe heel abrasion is of concern to patients and shoe manufacturers, but little scientific information is available about this feature and its possible causes. The purpose of this study was to relate this phenomenon with biomechanical factors that could predispose to shoe heel abrasion. METHODS: Ninety-seven recruits (median age 25) were enrolled in this study. Shoe abrasion was assessed manually with a metric plastic tape on the posterior part of the heel that comes in contact with the ground. The number of sprains, foot alignment, and calf muscle shortening (Silfverskiold test) was also assessed in order to relate it with shoe heel abrasion. After using our exclusion criteria, 86 recruits and 172 were considered for this study. RESULTS: The most common abrasion site was the lateral portion of the heel surface (50 %). Forty-four percent of the participants had neutral hind-foot alignment and 39 % had valgus alignment. Twenty-six (30 %) patients have had previous ankle or foot sprains. Neutral foot was related with less calf muscle shortening. On the other hand, valgus hind-foot alignment was more associated with Achilles shortening (p < 0.05). Patients with neutral alignment were associated with more uniform shoe heel abrasion and varus feet were associated with more central and lateral abrasion (p < 0.05). The pattern of shoe heel abrasion was not statistically related with calf muscle shortening nor with number of sprains. CONCLUSION: This study was able to correlate shoe heel abrasion with biomechanical causes (neutral alignment-uniform abrasion/varus alignment-central and lateral abrasion). More effort has to be done to continue evaluating outsole abrasion with its possible biomechanical cause in order to predict and treat possible associated injuries.

Prospective evaluation of protocol for surgical treatment of lesser MTP joint plantar plate tears.

BACKGROUND: Instability of the lesser metatarsophalangeal (MTP) joints is a common cause of deformity and pain. The purpose of this study was to prospectively evaluate the surgical outcomes for the different grades of plantar plate tears and propose a treatment protocol. METHODS: Sixty-eight patients (100 MTP joints) were prospectively enrolled and graded according to the anatomical grade system for plantar plate tears. Based on this classification, the appropriate surgical procedure was chosen as follows: grades 0 and I, thermal shrinkage with radiofrequency; grades II and III, direct reinsertion of the plantar plate; and grade IV, flexor-to-extensor tendon transfer. All surgical procedures were associated with a Weil metatarsal osteotomy. Evaluations were performed before and after surgical treatment with a mean follow-up of 2 years (12-36 months), using clinical and radiological parameters: American Orthopaedic Foot and Ankle Society (AOFAS) Lesser MTP-IF Scale, visual analog scale (VAS), ground touch, joint stability, and toe purchase. RESULTS: The analysis of the clinical parameters demonstrated a significant improvement of all groups (P < .0001) after surgical treatment, but grade IV had less VAS improvement and a fair AOFAS average score (72 points). All groups improved regarding physical examination parameters, but grade I, III, and IV tears had proportionally less stable MTP joints following surgery, as well as a lower proportion of normal postoperative toe purchase and ground touch. All groups showed a significant improvement regarding radiographic parameters. CONCLUSION: All groups of operatively treated patients had significant improvement with regard to subjective and objective parameters. Grades I, III, and IV presented inferior results compared with grades 0 and II. LEVEL OF EVIDENCE: Level IV, case series.

Lesser metatarsal phalangeal joint arthroscopy: anatomic description and comparative dissection.

PURPOSE: The aim of this article is to describe the normal arthroscopic anatomy of the lesser metatarsophalangeal (MTP) joints and compare it with that seen in open dissection in cadaveric models. METHODS: We performed arthroscopic examination of 18 MTP joints of 6 normal fresh frozen feet. The second, third, and fourth MTP joints were studied because of the higher incidence of pathologic conditions found in these joints. During arthroscopy, each anatomic structure identified was named and marked with different colored sutures using straight suture needles. After the arthroscopic procedure of identification and marking, each MTP joint was dissected, and all the anatomic structures were grossly identified. With these data, the correlation between the arthroscopic and the direct visualization of a normal MTP joint was established. RESULTS: Considering the joint regions, we found that the examination accuracy of the medial gutter was 91%, whereas the central joint accuracy reached 100% and the accuracy of the lateral gutter was 98%. The overall arthroscopic accuracy for the lesser MTP joints was 96%. CONCLUSIONS: There is a high level of anatomic accuracy at the lesser MTP joint with arthroscopy. CLINICAL RELEVANCE: The high overall level of anatomic accuracy of lesser MTP joint arthroscopy (96%) allows us to consider this resource as a valuable tool in the diagnosis and treatment of these joints, expanding the spectrum of indications using this method.

Classification of metatarsophalangeal joint plantar plate injuries: history and physical examination variables.

Although metatarsophalangeal (MTP) plantar plate tears are common, they are still often missed. The purpose of this study is to find the best clinical variables to define and grade the plantar plate injuries. Sixty-eight patients (100 MTP joints) were graded arthroscopically and divided into five groups (0 to IV) according to the anatomical classification. Their medical records were reviewed to establish correlations of clinical findings with the anatomical lesions. The positive correlations found were acute pain, widening of the interdigital space, loss of ground touch, positivity of the MTP joint drawer test, reduction of the toe purchase, and toe supination. The drawer test is the most reliable and accurate tool to classify and grade the plantar plate lesion, followed by ground touch and rotational deformities. It is possible to improve the accuracy of diagnosis of plantar plate tears by means of the combination of both clinical history and physical examination data.