Diagnosis and Management of Infected Total Ankle Replacements.

As the number of primary total ankle replacements increases for treatment of end-stage ankle arthritis, failures are also expected to rise. Periprosthetic joint infection is among the causes of failures and has been reported to be as high as 5%. Diagnosis is usually made by a combination of clinical examination findings, imaging, laboratory, and microbiological workup. Management is generally separated into limb salvage or amputation. Limb salvage can be challenging and may involve a single versus staged approach. Options include revision arthroplasty or arthrodesis procedures (ankle versus tibiotalocalcaneal), and a multidisciplinary approach is sought to eradicate infection before definitive management.

A Novel Technique for Lateral Ankle Ligament Reconstruction with Total Ankle Total Talus Replacement: A Case Report.

CASE: A 65-year-old man with severe left talar avascular necrosis, arthritis, and chronic lateral ankle instability underwent total ankle total talus replacement (TATTR) with lateral ligament reconstruction. Tibial component placement was performed using preoperative computed tomography navigation and patient-specific guides. A custom, total talus replacement to mate with the fixed-bearing tibial component was implanted. Last, a modified Brostrom procedure was performed to restore lateral ankle stability. The patient has performed well through 1 year with improved pain-free function. CONCLUSION: This case report details a novel technique for performing a modified Brostrom procedure in conjunction with TATTR to restore lateral ankle stability.

Minimally Invasive Repair of Subacute Achilles Tendon Ruptures: A Report of 2 Cases.

LEVEL OF EVIDENCE: Level IV: Case report.

Surgical Repair of Posttraumatic Hallux Valgus Deformity in a Collegiate Football Player: A Case Report.

CASE: We report a rare case of posttraumatic hallux valgus in a collegiate football player after an acute medial collateral ligament tear of the first metatarsophalangeal joint. The patient was treated with a modification of the modified McBride technique, using an all-suture anchor for the medial ligamentous complex repair. There was return to sport at 5 months and a Foot and Ankle Outcome Score of 95% at 10 months. CONCLUSION: A modified McBride procedure further modified with the utilization of an all-suture anchor for the medial ligamentous complex repair can result in correction of deformity, pain-free movement and return to sport.

Post-Traumatic Hallux Valgus: A Modified Surgical Technique.

Post-traumatic hallux valgus, a turf toe variant, is a rare, yet limiting injury. According to the literature, the deformity has been associated with acute medial collateral ligament tears, turf toe variant injuries, Lisfranc injury patterns, and first metatarsal fractures. There have been few documented cases of post-traumatic hallux valgus secondary to medial collateral ligament tears, and the treatment has been variable. Some authors have described direct end-to-end repair of the ligament to address the deformity, while others have described a modified McBride bunionectomy involving a Silver bunionectomy, lateral soft tissue release, and medial capsular and ligamentous repair. We propose a modified technique similar to the modified McBride bunionectomy, however, with the use of an all-suture anchor in the medial capsular and ligamentous repair. Our belief is that the all-suture anchor will allow for a stronger repair that will meet the physical demands of everyday ambulation and athletic participation. We used this technique in an individual who had evidence of a medial ligamentous complex injury of the hallux on MRI and failed conservative management. Postoperatively, the patient is immobilized until they can begin working on range of motion, strengthening, and finally to achieve return to full activity and sports.

Chronic Achilles Ruptures: Reconstructive Options.

Achilles tendon ruptures, if neglected or identified late, lead to impairments in function and gait. Surgical reconstruction is typically required to restore the resting length and tension to the gastrocnemius-soleus complex. A variety of reconstructive options have been described, depending on several factors, including chronicity, residual gap size, remaining tissue quality and vascularity, location of tendon rupture or deficiency, and patient-specific factors. Despite the many surgical options described from local soft-tissue rearrangements and tendon transfers, to the use of allograft tissue and synthetic material augmentation, there is understandably a paucity of evidence-based guidelines available to direct surgeons in the optimal procedure for each patient-specific situation. Reconstructive options for the patient with a chronic Achilles rupture are detailed and reviewed here, to serve as a framework for the treating surgeon in these complex cases.

Conservative Management of Metatarsalgia and Lesser Toe Deformities.

There are several forefoot conditions that can result in metatarsal head pain. Various points of the gait cycle can predispose the metatarsal heads to pain based on intrinsic and extrinsic imbalances. Metatarsalgia can further be classified according to primary, secondary, or iatrogenic etiologies. Within these groups, conservative management is the first line of treatment and can often obviate surgical intervention. Depending on the cause of pain, proper shoewear, orthoses, and inserts coupled with targeted physical therapy can alleviate most symptoms of metatarsalgia and lesser toe deformities.

Tendon transfers for the drop foot.

The paralytic drop foot represents a challenging problem for even the most experienced orthopedic surgeon. Careful patient selection, thorough preoperative examination and planning, and application of tendon transfer biomechanical and physiologic principles outlined in this article can lead to successful results, either through a posterior tibialis tendon transfer, Bridle transfer, or variations on these procedures. Achilles lengthening or gastrocnemius recession may also be needed at the time of tendon transfer.

Total Ankle Arthroplasty with a Modern Fixed-Bearing System: The Salto Talaris Prosthesis.

INTRODUCTION: The Salto Talaris total ankle replacement is a fixed-bearing system that integrates a mobile tibial trial component that allows self-alignment on the distal tibial resected surface, as guided by the talar component. STEP 1 PREOPERATIVE PLANNING: A thorough preoperative assessment is crucial. STEP 2 ANTERIOR APPROACH: Meticulous soft-tissue handling is essential. STEP 3 TIBIAL PREPARATION: Use intraoperative fluoroscopy and direct inspection to determine the appropriate alignment, tibial component size, and resection level as guided by the external tibial alignment and cutting guides. STEP 4 TALAR PREPARATION: Use the largest talar component that does not impinge on either malleolus. STEP 5 IMPLANT TRIALING: Careful assessment of ankle range of motion and stability in conjunction with selection of an appropriately sized polyethylene insert and consideration of additional soft-tissue balancing procedures are key to implantation of a well-balanced stable ankle replacement. STEP 6 FINAL IMPLANT PLACEMENT AND CLOSURE: Completion of a meticulous, layered soft-tissue closure over a drain and placement of a well-padded short leg cast are key to soft-tissue stability and wound-healing. STEP 7 POSTOPERATIVE CARE: Wound and soft-tissue healing drive the initial postoperative management. RESULTS: Published, prospective studies of the clinical outcomes of modern fixed-bearing total ankle systems are limited in the United States, mainly because FDA approval of these systems is more recent than that of other mobile-bearing options. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

Early prospective clinical results of a modern fixed-bearing total ankle arthroplasty.

BACKGROUND: Several fixed-bearing total ankle arthroplasty systems are available in the United States. We report on the early clinical results of the largest known cohort of patients in the United States who received a Salto Talaris total ankle replacement for the treatment of end-stage arthritis of the ankle. METHODS: We prospectively followed sixty-seven patients with a minimum clinical follow-up of two years. Patients completed standardized assessments and underwent physical examination, functional assessment, and radiographic evaluation preoperatively and at six weeks, three months, and six months postoperatively and yearly thereafter through their most recent follow-up. RESULTS: Implant survival at a mean follow-up time of 2.8 years was 96% when metallic component revision, removal, or impending failure was used as the end point. Three patients developed aseptic loosening, and all instances involved the tibial component. One of the three patients underwent revision to another fixed-bearing total ankle arthroplasty system, one patient is awaiting revision surgery, and the third patient has remained minimally symptomatic and fully functional without additional surgery. Forty-five patients underwent at least one additional procedure at the time of the index surgery. The most common concurrent procedure performed was a deltoid ligament release (n = 21). Eight patients underwent additional surgery following the index arthroplasty, most commonly debridement for medial and/or lateral impingement (n = 4). As of the most recent follow-up, patients demonstrated significant improvement in pain scores, American Orthopaedic Foot & Ankle Society hindfoot score, and functional scores. CONCLUSIONS: Early clinical results indicate that the Salto Talaris fixed-bearing total ankle arthroplasty system can provide significant improvement in pain, quality of life, and standard functional measures in patients with end-stage ankle arthritis. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Pigmented villonodular synovitis of the ankle: an anterior-posterior technique for excision.

Because of its high recurrence rate, complete excision with total synovectomy is crucial for diffuse pigmented villonodular synovitis (DPVNS). Regardless of location, surgical approach requires meticulous soft tissue management and full joint exposure to assure complete tumor excision. In the ankle, PVNS can be present in the medial and lateral gutters, as well as extend along the syndesmotic ligament, flexor and peroneal tendon sheaths, and adjacent joints (ie, subtalar and midtarsal joints). The authors describe an open, anterior-posterior technique for excision of DPVNS lesions from the ankle joint with erosive lesions of the tibia and talus, as well as from the flexor hallucis longus and peroneal tendon sheaths. Whereas previously described dual-incision techniques have focused on posteromedial and posterolateral approaches to the ankle, the authors' posterior exposure, in particular, uses a midline skin incision and a longitudinal split of the Achilles tendon. This provides an excellent exposure and minimizes potential wound healing complications.

Paecilomyces lilacinus septic olecranon bursitis in an immunocompetent host.

Paecilomyces lilacinus is a filamentous fungus that is a rare cause of infection in immunocompromised human hosts. We present a case of lilacinus septic olecranon bursitis in an otherwise healthy 78-year-old male. This patient's case was complicated by wound breakdown after bursectomy and appropriate anti-fungal treatment, requiring a local soft tissue rearrangement. This case demonstrates the need for appropriate and timely medical and surgical treatment in infections involving lilacinus, which are not isolated solely to systemically immunocompromised and medically-ill patient populations. In cases where the patient is systemically immumocompromised or has been rendered locally immunocompromised, it is essential to obtain a full culture work-up, including fungi.

Incidence of wrong-site surgery among foot and ankle surgeons.

In 1998, the American Academy of Orthopaedic Surgeons initiated the "sign your site" campaign to address the issue of wrong-site surgery (WSS). Using a confidential online survey sent to 1094 active members of the American Academy of Foot and Ankle Surgeons, the authors assessed participation in the "sign your site" campaign and the occurrence of WSS encountered during their careers. A total of 319 responses were received (response rate = 29.2%). In all, 41 of 310 respondents (13%) reported performing WSS at least once, with 4 surgeons (1%) reporting the occurrence twice in their careers; 70 of 310 (23%) surgeons reported that they had prepped the wrong surgical site, but the error was recognized prior to making an incision. In all, 302 of 309 respondents (97.7%) reported that they were aware of the "sign your site" initiative. Since the introduction of the campaign, significantly more (89.2% vs 49.2%) foot and ankle surgeons routinely mark the surgical site (P < .001). The Joint Commission revised the universal protocol for surgical site verification requiring an individual directly involved in a surgical procedure to mark the site as of January 1, 2009. The authors believe this revision will lower the incidence of WSS further.

Open Reduction and Internal Fixation of Intra-Articular Calcaneal Fractures Via an Extensile Lateral Approach.

INTRODUCTION: Although displaced intra-articular calcaneal fractures were historically treated nonoperatively because of unreliable outcomes, they are now commonly treated with open reduction and internal fixation (ORIF). STEP 1 PREOPERATIVE PLANNING AND OPERATIVE SETUP: Coronal images are most helpful. STEP 2 INCISION AND SOFT-TISSUE MANAGEMENT: Elevate the flap using the "no-touch" technique to minimize wound complications. STEP 3 REDUCE POSTERIOR FACET AND PERFORM PROVISIONAL STABILIZATION: Achieve anatomic reduction of the medial calcaneal wall before proceeding with the remainder of the fracture reduction. STEP 4 APPLY LAG FIXATION AND A LATERAL NEUTRALIZATION PLATE: Use a traditional nonlocking plate and be sure that at least one lag screw achieves purchase. STEP 5 CLOSE WOUND: Use the "no-touch" technique, with the goal of tension-free wound closure. STEP 6 POSTOPERATIVE CARE: Watch closely for drainage or delayed healing. RESULTS & PREOP/POSTOP IMAGES: ORIF is a viable treatment option for displaced intra-articular calcaneal fractures without contraindication for older patients. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

Interrater reliability of identifying indicators of posterior ligamentous complex disruption when plain films are indeterminate in thoracolumbar injuries.

BACKGROUND: The Spine Trauma Study Group (STSG) has proposed a novel thoracolumbar injury classification system and score (TLICS) in an attempt to define traumatic spinal injuries and direct appropriate management schemes objectively. The TLICS assigns specific point values based on three variables to generate a final severity score that guides potential treatment options. Within this algorithm, significant emphasis has been placed on posterior ligamentous complex (PLC) integrity. The purpose of this study was to determine the interrater reliability of indicators surgeons use when assessing PLC disruption on imaging studies, including computed tomography (CT) and magnetic resonance imaging (MRI). METHODS: Orthopedic surgeons and neurosurgeons retrospectively reviewed a series of thoracolumbar injury case studies. Thirteen case studies, including images, were distributed to STSG members for individual, independent evaluation of the following three criteria: (1) diastasis of the facet joints on CT; (2) posterior edema-like signal in the region of PLC components on sagittal T2-weighted fat saturation (FAT SAT) MRI; and (3) disrupted PLC components on sagittal T1-weighted MRI. Interrater agreement on the presence or absence of each of the three criteria in each of the 13 cases was assessed. RESULTS: Absolute interrater percent agreement on diastasis of the facet joints on CT and posterior edema-like signal in the region of PLC components on sagittal T2-weighted FAT SAT MRI was similar (agreement 70.5%). Interrater agreement on disrupted PLC components on sagittal T1-weighted MRI was 48.9%. Facet joint diastasis on CT was the most reliable indicator of PLC disruption as assessed by both Cohen's kappa (kappa = 0.395) and intraclass correlation coefficient (ICC 0.430). CONCLUSIONS: The interrater reliability of assessing diastasis of the facet joints on CT had fair to moderate agreement. The reliability of assessing the posterior edema-like signal in the region of PLC components was lower but also fair, whereas the reliability of identifying disrupted PLC components was poor.

Assessment of injury to the thoracolumbar posterior ligamentous complex in the setting of normal-appearing plain radiography.

BACKGROUND CONTEXT: The posterior ligamentous complex (PLC) is thought to contribute significantly to the stability of thoracolumbar spine. Obvious translation or dislocation of an interspace clearly denotes injury to the PLC. A recent survey of the Spine Trauma Study Group indicated that plain radiographic findings, if present, are most helpful in determining PLC injury. However, confusion exists when plain radiography shows injury to the anterior spinal column without significant kyphosis or widening of the posterior interspinous space. PURPOSE: The objective of this study is to identify imaging parameters that may suggest a disruption of the posterior ligamentous complex of the thoracolumbar spine in the setting of normal-appearing plain radiographs. This study was performed, in part, as a pilot study to determine critical imaging parameters to be included in a future prospective, randomized, multicenter study. STUDY DESIGN/SETTING: Survey analysis of the Spine Trauma Study Group. PATIENT SAMPLE: None. OUTCOME MEASURES: Compilation and statistical analysis of survey results. METHODS: Based on a systematic review of the English literature from 1949 to present, we identified a series of traits not found on plain X-rays that were consistent with PLC injury. This included five imaging findings on either computed tomography (CT) scans or magnetic resonance imaging (MRI) and several physical examination features. These items were placed on a survey and sent to the members of the Spine Trauma Study Group. They were asked to rank the items from most important to least important in representing an injury to the PLC in the setting of normal-appearing plain radiographs. RESULTS: Thirty-three of 47 surveys were returned for final analysis. Thirty-nine percent (13/33) of the members ranked "disrupted PLC components (i.e., interspinous ligament, supraspinous ligament, ligamentum flavum) on T1 sagittal MRI" as the most important factor in determining disruption of PLC. When analyzed with a point-weighted system, "diastasis of the facet joints on CT" received the most points, indicating that this category was ranked high by the majority of the members of the group. The members were also given freedom to add other criteria that they believed were important in determining PLC integrity in the setting of normal-appearing plain radiograph. Of the other criteria suggested, one included a physical finding and the other a variant of MR sequencing. CONCLUSIONS: In a setting of normal-appearing plain radiographs, PLC injury as displayed on T1-weighted MRI and diastasis of the facet joints on CT scan seem to be the most popular determinants of probable PLC injury among members of the Spine Trauma Study Group. Between MRI and CT scan, most members feel that various characteristics on MRI studies were more helpful.

Confusion regarding mechanisms of injury in the setting of thoracolumbar spinal trauma: a survey of The Spine Trauma Study Group (STSG).

The Spine Trauma Study Group (STSG) developed the thoracolumbar injury severity score to direct the management of thoracolumbar spine injuries. The original system is based on 3 variables: the mechanism of injury as determined by imaging studies, the integrity of the posterior ligamentous complex, and the neurologic status of the patient. Considerable controversy exists among treating physicians in classifying injury mechanisms. The purpose of this study was to survey the STSG on case examples related to the mechanism of thoracolumbar injury. A 2-question survey regarding thoracolumbar injury mechanisms and scoring was distributed to members of the STSG. A total of 27 STSG members completed surveys on defining and scoring thoracolumbar injury mechanisms. Data from these completed surveys were analyzed using a 2-tailed Fisher exact test on a chi2 contingency table. Sixty-seven percent of physicians preferred a definition incorporating posterior ligamentous complex disruption without posterior vertebral body retropulsion over the location of the axis of rotation in differentiating flexion-distraction from advanced stage flexion-compression injuries, representing a statistically significant difference (P=0.0285). There was no statistical consensus on the scoring emphasizing a primary and secondary mechanism of injury in complex injury patterns. Despite the statistical consensus to 1 survey question, there seems to be no dominating opinion on distinguishing thoracolumbar injury mechanisms. Perhaps identifying objective findings on imaging studies and clinical examination in place of guessing injury mechanisms may allow for a more reliable and valid thoracolumbar injury classification system.

Assessment of injury to the posterior ligamentous complex in thoracolumbar spine trauma.

BACKGROUND CONTEXT: Posterior ligamentous complex (PLC), consisting of supraspinous ligament (SSL), interspinous ligament (ISL), ligamentum flavum (LF), and the facet joint capsules is thought to contribute significantly to the stability of thoracolumbar spine. Currently, no consensus exists on radiographic imaging parameters that may indicate injury to the posterior ligamentous complex. PURPOSE: To identify imaging parameters that may suggest a disruption of the PLC of the thoracolumbar spine. STUDY DESIGN/SETTING: A survey analysis of members of the Spine Trauma Study Group. PATIENT SAMPLE: None. OUTCOMES MEASURES: Compilation of survey results. METHODS: An extensive review of the literature from 1949 to the present was performed to identify key radiographic elements that have been suggested as indicators of PLC injury. Twelve items identified as such were placed on a survey and sent to the members of the Spine Trauma Study Group. They were asked to rank the items from most important to least important, and the results were compiled for analysis. RESULTS: Twenty-eight surveys were returned for final analysis. Fifty-percent (14/28) of the members ranked "vertebral body translation" on plain radiographs as the most important factor in determining disruption of PLC. Plain radiographic signs were ranked higher than computed tomography or magnetic resonance imaging indicators, and history of the mechanism ranked lowest. The members were also given freedom to add other criteria that they felt were important in determining PLC integrity. "Interspinous spacing 7 mm greater than that of level above or below on antero posterior plain X-rays" was the only new category that was suggested. CONCLUSION: Plain radiographic findings were felt to be most helpful in determining PLC injury by the members of the Spine Trauma Study Group. Physical examination findings and history of the mechanism of injury were ranked lower than imaging studies. Future analysis should focus on indicators of PLC injury when plain radiographic findings are either subtle or not present.