Two-Year Survivorship and Patient-Reported Outcomes of a Prospectively Enrolled Cohort of INFINITY Total Ankle Arthroplasties.

BACKGROUND: The INFINITY total ankle implant is a widely and successfully used option for total ankle arthroplasty. The purpose of this study is to assess the 2-year survivorship, complication rates, patient-reported outcomes, and radiologic findings of prospectively enrolled patients undergoing a fixed-bearing total ankle arthroplasty (TAA). This study sought to determine if factors such as traditional vs patient-specific instrumentation, preoperative degree of arthritis, deformity, or etiology of arthritis impact surgical or clinical outcomes. METHODS: A total of 143 prospectively enrolled patients (148 ankles) underwent TAA with a fixed-bearing total ankle implant between 2017 and 2019 at 9 different institutions by 9 different surgeons. A total of 116 completed 2-year follow-up. Patients were stratified by instrumentation used, degree of preoperative deformity, the Canadian Orthopaedic Foot and Ankle Society (COFAS) grading system, and etiology of arthritis. Outcomes used included implant survivorship and adverse events within 2 years of surgery. Additionally, patient-reported outcomes and radiographs were collected at 6-month, 1-year, and 2-year postoperatively. PROMs used included Ankle Osteoarthritis Score (AOS), Patient-Reported Outcomes Measurement Information System (PROMIS) global health score, the Foot and Ankle Outcome Score (FAOS), and patient satisfaction (rated from excellent to poor). RESULTS: Implant survivorship at 2 years was 97.79%. There were 17 reoperations (11.5%), with 4 of the implants requiring revision (2.7%). Significant improvements in all PROMs were observed among all subgroups at all postoperative time points without significant variation between subgroups. Patients classified as COFAS type 2 arthritis preoperatively demonstrated significantly more improvement in FAOS Total Symptom Score at the 1- and 2-year measurements than COFAS type 3 patients at both time points. CONCLUSION: Total ankle arthroplasty with a fixed-bearing implant system is a safe and reliable treatment option for patients with end-stage arthritis regardless of degree of deformity or COFAS grading. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Gastrocnemius recession for chronic noninsertional Achilles tendinopathy.

BACKGROUND: In patients with chronic Achilles tendinopathy, several operative techniques have been described for treatment. A case report has shown that gastrocnemius recession as treatment can normalize MRI findings and relieve clinical symptoms consistent with chronic Achilles tendinopathy. The purpose of this study was to present the results of the treatment of chronic Achilles tendinopathy with gastrocnemius recession. METHODS: Of 12 patients, 8 (7 females, 1 male) who underwent gastrocnemius recession for refractory Achilles tendinopathy between July 2004 and January 2009 were available for follow-up. All patients filled out a SF-36 health survey, a foot function index, an AOFAS ankle and hindfoot scale, and a simple survey formulated by our group of investigators. Of the 8 patients, 7 were available to return for clinical assessment. Patients had an average age of 49.9 years (SD = 11.6) at the time of surgery and average time of follow-up was 34.6 months (SD = 18.1). RESULTS: The mean pain score (VAS 0-10 scale) significantly decreased from 7.3 (SD = 1.7) preoperatively to 1 (SD = 1.8) postoperatively at the time of follow-up (P < .001). The mean AOFAS ankle and hindfoot score was 94.4 (SD = 9.8), which was significantly improved when compared with previously published scores for patients who underwent Achilles debridement with FHL transfer (P = .007). All 8 categories on the SF-36 health survey showed no significant difference with published data for US population values and previously published data for patients who underwent FHL transfer. CONCLUSION: Gastrocnemius recession for the treatment of refractory Achilles tendinopathy was a viable treatment option following the failure of nonoperative management. All 8 of our patients had excellent pain relief, good clinical outcome, and were satisfied at the time of follow-up.

Republication of "Postoperative Narcotic Prescription Practice in Orthopedic Foot and Ankle Surgery".

Background: The misuse and abuse of opioid pain medications have become a public health crisis. Because orthopedic surgeons are the third highest prescribers of opioids, understanding their postoperative pain medication prescribing practices is key to solving the opioid crisis. To this end, we conducted a study of the variability in orthopedic foot and ankle surgery postoperative opioid prescribing practice patterns. Methods: Three hundred fifty orthopedic foot and ankle surgeons were contacted; respondents completed a survey with 4 common patient scenarios and surgical procedures followed by questions regarding typical postoperative pain medication prescriptions. The scenarios ranged from minimally painful procedures to those that would be expected to be significantly more painful. Summaries were calculated as percentages and chi-square or Fisher exact tests were used to compare survey responses between groups stratified by years in practice and type of practice. Results: Sixty-four surgeons responded to the survey (92.8% male), 31% were in practice less than 5 years, 34% 6 to 15 years and 34% more than 15 years. For each scenario, there was variation in the type of pain medication prescribed (scenario 1: 17% 5 mg hydrocodone, 22% 10 mg hydrocodone, 52% oxycodone, and 3% oxycodone sustained release [SR]; scenario 2: 15% 5 mg hydrocodone, 13% 10 mg hydrocodone, 58% oxycodone, and 9% oxycodone SR; scenario 3: 11% 5 mg hydrocodone, 13% 10 mg hydrocodone, 56% oxycodone, and 14.1% oxycodone SR; scenario 4: 3% 5 mg hydrocodone, 5% 10 mg hydrocodone, 44% oxycodone, and 45% oxycodone SR) and the number of pills dispensed. Use of multimodal pain management was variable but most physicians use regional nerve blocks for each scenario (76%, 87%, 69%, 94%). Less experienced surgeons (less than 5 years in practice) supplement with tramadol more for scenario 1 (P = .034) as well as use regional nerve blocks for scenario 2 (P = .039) more than experienced surgeons (more than 15 years in practice). Conclusion: It is evident that variation exists in narcotic prescription practices for postoperative pain management by orthopedic foot and ankle surgeons. With new AAOS guidelines, it is important to try to create some standardization in opioid prescription protocols.

Operative correction of arch collapse with forefoot deformity: a retrospective analysis of outcomes.

BACKGROUND: There are many forefoot deformities, including hallux valgus, forefoot overload, and hammertoe that are treated as unrelated problems with multiple different techniques. Currently, there has been renewed interest in the role of a gastrocnemius contracture on foot deformities. Our objective was to review a specific surgical treatment plan for forefoot deformities classified by us as Type 2 arch collapse and evaluate the outcomes. MATERIALS AND METHODS: We retrospectively reviewed the charts of 374 patients who underwent foot procedures to treat deformity classified as a Type 2 arch collapse. Data was collected regarding complications and need for secondary surgery. A phone survey was performed to assess patient satisfaction, pain level, and Foot Function Index (FFI) scores. RESULTS: Of the 374 patients (412 feet), there was a 96% (357 of 371 feet) union rate at the first tarsometatarsal joint and 98% (227 of 232 feet) union rate at metatarsal shortening osteotomy sites. Recurrence of hallux valgus was 2.7% (7 of 256 feet), while hallux varus occurred in 1.6% (4 of 256 feet). There were 292 patients (78%) available for phone interview. Of those patients, 88% were satisfied with the results of the procedure. The subset of procedures relating to the highest mean FFI was hammertoe correction (22.2) and the highest mean pain score was related to metatarsal shortening osteotomy (2.6). CONCLUSION: Utilizing the arch collapse model, operative treatment of forefoot deformities with a combination of procedures including gastrocnemius recession, first TMT fusion, modified McBride, hammertoe correction, and metatarsal shortening osteotomy can produce good satisfaction rates with low complication rates.

Closed intramedullary screw fixation for nonunion of fifth metatarsal Jones fracture.

BACKGROUND: Nonunion following a proximal fifth metatarsal metaphyseal-diaphyseal or Jones fracture can cause considerable pain with high morbidity and loss of work. Treatment should aim for early union, thus allowing early return to activity. The present study evaluated the outcomes and the time required for union following closed intramedullary screw fixation for this condition. MATERIALS AND METHODS: Between January 2005 to August 2009, 14 patients were diagnosed with nonunion following a Jones fracture. Mean age at surgery was 49 years. Mean duration from injury to surgery was 28 weeks. All nonunions were fixed with a single intramedullary screw inserted from the base of the fifth metatarsal without opening the nonunion site. Serial postoperative radiographs were evaluated to determine union. Time required for return to activity was determined. Outcome was assessed with help of pain scores. Mean followup was 27 months. RESULTS: Union was achieved in all 14 patients with one delayed union. Mean time to union was 13.3 (range, 8 to 20) weeks. All patients were able to start unassisted full weightbearing without pain at mean 10.2 weeks. Overall pain score improved from a preoperative mean of 5.4 to postoperative mean of 1.0. Complications included one deep infection, one delayed wound healing and one sural neuroma. CONCLUSION: Closed intramedullary screw fixation achieved an excellent union rate when used in the treatment of nonunion of a Jones fractures.

Outcomes following midfoot arthrodesis for primary arthritis.

BACKGROUND: Primary midfoot arthritis is a disabling painful condition of the foot. The aim of the study was to assess the functional outcomes following midfoot arthrodesis for primary midfoot arthritis. MATERIALS AND METHODS: Between 2000 and 2006, 95 patients (104 feet) underwent midfoot arthrodesis for primary midfoot arthritis. Midfoot collapse, if present, was corrected at the time of arthrodesis. Mean age at surgery was 62 years. Gastrocnemius contracture was seen in 81 (78%) feet and was treated with a recession. Radiographs were reviewed for correction of deformity. Complications and reoperations were noted. Outcome evaluation included pain, American Orthopaedic Foot Ankle Society (AOFAS) midfoot score and patient satisfaction. Outcomes were available in 68 patients (74 feet) with mean followup of 56 (range, 24 to 102) months. RESULTS: We achieved union in 96 out of 104 feet (92 %). There was one delayed union and eight nonunions. Major complications (4/104, 4%) included three deep infections and one chronic regional pain syndrome. Reoperations were required in 11 feet in addition to 26 symptomatic hardware removals. Radiographs showed a significant improvement in the talo-first metatarsal angle and medial cuneiform height. Pain improved from preoperative mean of 7 ± 2 to postoperative mean of 2 ± 2. AOFAS score improved from preoperative mean of 32 (range, 25 to 43) to postoperative mean of 79 (range, 65 to 90). Ninety percent of patients were satisfied with the final result. CONCLUSION: Primary or degenerative arthritis of the midfoot with refractory symptoms was treated with midfoot arthrodesis with good results and a low incidence of nonunion.

Complications Associated with Peripheral Nerve Blocks.

Outpatient orthopedic surgery is gradually becoming the standard across the country, as it has been found to significantly lower costs without compromising patient care. Peripheral nerve blocks (PNBs) are largely what have made this transition possible by providing patients excellent pain control in the immediate postoperative period. However, with the increasing use of PNBs, it is important to recognize that they are not without complications. Although rare, these complications can cause patients a significant amount of morbidity. It is important for surgeons to know the risks of peripheral nerve blocks and to inform their patients.

Comparing 4-Year Changes in Patient-Reported Outcomes Following Ankle Arthroplasty and Arthrodesis.

BACKGROUND: The rate of total ankle arthroplasty (TAA) is increasing relative to ankle arthrodesis (AA) for patients seeking surgical treatment for end-stage ankle arthritis. Patients and providers would benefit from a more complete understanding of the rate of improvement, the average length of time to achieve maximal function and minimal pain, and whether there is a greater decline in function or an increase in pain over time following TAA compared with AA. The objectives of this study were to compare treatment changes in overall physical and mental function and ankle-specific function, as well as pain intensity at 48 months after TAA or AA in order to determine if the improvements are sustained. METHODS: This was a multisite prospective cohort study that included 517 participants (414 TAA and 103 AA) who presented for surgical treatment. Participants were compared 48 months after surgery using the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living and Sports subscales (0 to 100 points), the Short Form-36 (SF-36) Physical and Mental Component Summary (PCS and MCS) scores (0 to 100 points), and pain scores (0 to 10 points). RESULTS: Both groups achieved significant improvement in the 2 FAAM measures, the SF-36 PCS score, and all of the pain measures at 48 months after surgey (p < 0.001). Mean improvements from baseline in patients undergoing TAA for the FAAM Activities of Daily Living, FAAM Sports, and SF-36 scores were at least 9 points, 8 points, and 3.5 points, respectively, which were higher than in those undergoing AA. Mean improvements in worst and average pain were at least 0.9 point higher in patients undergoing TAA than in those undergoing AA at 12, 24, and 36 months. These differences were attenuated by 48 months. For both treatments, all improvements from baseline to 24 months had been maintained at 48 months. CONCLUSIONS: When both procedures are performed by the same group of surgeons, patients who undergo TAA or AA for end-stage ankle arthritis have significant improvement in overall function, ankle-specific function, and pain at 48 months after surgery, with better functional improvement in the TAA group. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Gastrocnemius recession to treat isolated foot pain.

BACKGROUND: Gastrocnemius recession is performed to correct an isolated gastrocnemius equinus contracture of the ankle that may accompany foot and ankle pathology in the adult. It has been proposed that this equinus deformity leads to excessive strain throughout the foot, thus causing pain. This can manifest itself in the form of plantar fasciitis, metatarsalgia, posterior tibial tendon insufficiency, osteoarthritis, and foot ulcers. The purpose of this retrospective study was to review the efficacy of the gastrocnemius recession in providing pain relief for patients who have foot pain without structural abnormality who have failed conservative treatment and have an isolated gastrocnemius contracture. MATERIALS AND METHODS: Twenty-nine patients (34 feet) who had chronic foot pain without any structural abnormality other than an isolated gastrocnemius contracture underwent a gastrocnemius recession and were available for follow up at an average of 19.5 (range, 7 to 44) months. The outcome measurements were related to pain relief (Visual Analog Scale) and patient satisfaction. RESULTS: Preoperatively the average pain score was 8/10 which improved postoperatively to 2/10. Twenty-seven patients (93.1%) said they would recommend this procedure for isolated foot pain to a friend. Twenty-seven patients (93.1%) said they were satisfied with the results of the procedure. Twenty-three of 25 patients (92%) who had a unilateral procedure stated they would have the contralateral leg done if needed. CONCLUSION: Gastrocnemius recession was found to be an effective procedure when used to relieve recalcitrant foot pain in those patients with an isolated gastrocnemius contracture without deformity.

Surgical treatment of the ankle and foot in patients with rheumatoid arthritis.

Rheumatoid arthritis can be as devastating for the joints of the foot and ankle as for other joints of the lower and upper extremities. Early conservative treatment often is provided by a primary care provider or rheumatologist. Drug and injection therapies are used with footwear modifications, activity restrictions, and orthoses. Surgery often is the last treatment modality available to the patient; it has the potential to relieve pain and improve function.

Open reduction internal fixation versus primary arthrodesis for lisfranc injuries: a prospective randomized study.

BACKGROUND: Dislocations and fracture-dislocations involving the tarsometatarsal joint are a relatively common injury. These injuries are associated with long-term disability from subsequent painful osteoarthritis and residual deformity. This study evaluated whether performing a primary arthrodesis (PA) resulted in improved functional outcome and fewer subsequent surgeries as compared to primary open reduction and internal fixation (PORIF). MATERIALS AND METHODS: Forty patients with acute tarsometatarsal joint fractures or fracture dislocations were prospectively randomized to undergo either PORIF or PA. Clinical and radiographic examination, in addition to Short Form-36 (SF-36) and Short Musculoskeletal Function Assessment (SMFA) questionnaires, were evaluated at intervals of 3, 6, 12, and 24 months following surgery in 32 patients. A patient satisfaction phone survey was also performed. RESULTS: The rate of planned and unplanned secondary surgeries, including hardware removal and salvage arthrodesis, between ORIF and PA groups, 78.6% vs. 16.7% was significantly different. No statistically significant differences were found with physical functioning for the PORIF or PA groups with regard to SF-36 or SMFA scores at any followup time interval. However, time from injury had a significant effect with impaired functioning at three months compared to all future intervals. No difference in satisfaction rates were found between PORIF and PA at an average of 53 months in a phone survey. CONCLUSION: PA of tarsometatarsal joint injuries resulted in a significant reduction in the rate of followup surgical procedures if hardware removal is routinely performed with no significant difference in SF-36 and SMFA outcome scores when compared to PORIF.

Statistical Validation of the Grand Rapids Arch Collapse Classification.

BACKGROUND: The Grand Rapids Arch Collapse Classification system was devised in 2011 to assist physicians' and patients' understanding of the mechanisms underlying arch collapse. Five types of arch collapse are described, based on which part of the foot or ankle is affected. The purpose of this study was to determine the inter- and intrarater reliability of this classification system when used by physicians with various levels of training. METHODS: A senior author identified a stratified selection of 50 patients (10 per classification type) who presented with foot/ankle pain and suitable radiographs. A survey was designed using prediagnosis radiographs and clinical synopses of the patient's chart. The survey consisted of a description of the classification scheme and the 50 cases in a randomized order. Eight weeks later, they repeated the test to analyze for intra-rater agreement. RESULTS: Of the 33 physicians who received the survey, 26 completed the first round (16 attendings, 4 foot and ankle fellows, and 6 residents). Overall, there was substantial agreement among raters in all five types. Kappa scores for each type were 0.72, 0.65, 0.72, 0.70, 0.63, respectively. The combined kappa score was 0.68. After 8 weeks, 13 of the 26 participants repeated the study. A Kappa analysis was once again performed for the 13 respondents, which produced a substantial level of agreement with a value of 0.74 for intrarater reliability. CONCLUSION: The Grand Rapids Arch Collapse Classification system was designed to provide an accessible mechanism for physicians to consistently describe arch collapse, its effects, and the conditions associated with it. The utility of this system is wholly reliant on the repeatability among clinicians. This study has demonstrated that the classification system has substantial rates of reliability among physicians of different levels of experience and training. LEVEL OF EVIDENCE: Level IV.

Step Activity After Surgical Treatment of Ankle Arthritis.

BACKGROUND: Ambulatory activity is reduced in patients with ankle arthritis. In this study, we measured step activity over time in 2 treatment groups and secondarily compared step activity with results of patient-reported outcome measures (PROMs). METHODS: Patients who were treated with either ankle arthrodesis or ankle arthroplasty wore a step activity monitor preoperatively and at 6, 12, 24, and 36 months postoperatively. Changes from preoperative baseline in total steps per day and per-day metrics of low, medium, and high-activity step counts were measured in both treatment groups. Step activity was compared with each subject's PROM scores as reported on the Musculoskeletal Function Assessment (MFA) and the Short Form-36 (SF-36) physical function and bodily pain subscales. RESULTS: Of the 3 activity levels, combined group high-activity step counts showed the greatest increase (mean of 278 steps [95% confidence interval (CI), 150 to 407 steps], a 46% improvement from preoperatively). At 6 months, the mean high-activity step improvement for the arthroplasty group was 194 steps compared with a mean decline of 44 steps for the arthrodesis group (mean 238-step difference [95% CI, -60 to 536 steps]). By 36 months postoperatively, the greater improvement in high-activity steps for the arthroplasty versus the arthrodesis group was no longer present. There were no significant pairwise differences in improvement based on surgical treatment method at any individual follow-up time point. For a within-patient increase of 1,000 total steps, there was a mean change in the MFA, SF-36 physical function, and SF-36 bodily pain scores of -1.8 (95% CI, -2.4 to -1.2), 3.8 (95% CI, 2.8 to 4.8), and 2.8 (95% CI, 1.8 to 3.9), respectively (p < 0.0001 for all associations). There was no evidence that the association differed by study visit, or by study visit and surgical procedure interaction (p > 0.10). CONCLUSIONS: Surgical treatment of ankle arthritis significantly improves ambulatory activity, with greater change occurring at high activity levels. Improvement may occur more quickly following arthroplasty than arthrodesis, but at 3 years, we detected no significant difference between the 2 procedures. Step counts, while associated with PROMs, do not parallel them, and thus may be a useful supplementary measure, particularly in longitudinal studies. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Effectiveness and Safety of Ankle Arthrodesis Versus Arthroplasty: A Prospective Multicenter Study.

BACKGROUND: Newer designs and techniques of total ankle arthroplasty (TAA) have challenged the assumption of ankle arthrodesis (AA) as the primary treatment for end-stage ankle arthritis. The objective of this study was to compare physical and mental function, ankle-specific function, pain intensity, and rates of revision surgery and minor complications between these 2 procedures and to explore heterogeneous treatment effects due to age, body mass index (BMI), patient sex, comorbidities, and employment on patients treated by 1 of these 2 methods. METHODS: This was a multisite prospective cohort study comparing outcomes of surgical treatment of ankle arthritis. Subjects who presented after nonoperative management had failed received either TAA or AA using standard-of-treatment care and rehabilitation. Outcomes included the Foot and Ankle Ability Measure (FAAM), Short Form-36 (SF-36) Physical and Mental Component Summary (PCS and MCS) scores, pain, ankle-related adverse events, and treatment success. RESULTS: Five hundred and seventeen participants underwent surgery and completed a baseline assessment. At 24 months, the mean improvement in FAAM activities of daily living (ADL) and SF-36 PCS scores was significantly greater in the TAA group than in the AA group, with a difference between groups of 9 points (95% confidence interval [CI] = 3, 15) and 4 points (95% CI = 1, 7), respectively. The crude incidence risks of revision surgery and complications were greater in the AA group; however, these differences were no longer significant after adjusting for age, sex, BMI, and Functional Comorbidity Index (FCI). The treatment success rate was greater after TAA than after AA for those with an FCI of 4 (80% versus 62%) and not fully employed (81% versus 58%) but similar for those with an FCI score of 2 (81% versus 77%) and full-time employment (79% versus 78%). CONCLUSIONS: At 2-year follow-up, both AA and TAA were effective. Improvement in several patient-reported outcomes was greater after TAA than after AA, without a significant difference in the rates of revision surgery and complications. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Tibial compartment syndrome and the cavovarus foot.

Compartment syndrome of the leg is an orthopedic emergency that requires a high index of suspicion for diagnosis and a low threshold for surgical management to prevent devastating complications. Where the clinical findings are subtle, continuous monitoring of compartment pressures, with clinical correlation, is the key to diagnosis. Surgical management should include decompression of all four compartments and early rehabilitation to prevent ischemic contracture. If contracture develops, it may cause varying degrees of equinocavovarus deformity of the foot and ankle. Appropriate evaluation and careful surgical planning that considers all components of this complex deformity are essential for obtaining good clinical results.

Frequency and Impact of Adverse Events in Patients Undergoing Surgery for End-Stage Ankle Arthritis.

BACKGROUND: This study summarized the frequency and functional impact of adverse events (AEs) that occur after surgery for end-stage ankle arthritis (ESAA) to inform decision making. METHODS: This was a multisite prospective cohort study to compare ankle arthroplasty to ankle arthrodesis in the treatment of ESAA among 6 participating sites. We compared the risk and impact of nonankle AEs and ankle-specific AEs versus no AEs controlling for potential confounding factors, including operative procedure using multinomial logistic regression. We estimated differences in postoperative functional outcomes by AE occurrence using linear mixed effects regression. Among 517 patients who had surgery for ankle arthritis and completed the full baseline assessment, follow-up scores were available in 494 (95%) patients. RESULTS: There were a total of 628 reported AEs (477 in the arthroplasty group and 151 in the arthrodesis group). These occurred in 261 (63%) arthroplasty patients and 67 (65%) arthrodesis patients. There were 50 (8%) ankle-specific AEs. The risk of an ankle-specific AE was slightly higher in the arthrodesis group versus the arthroplasty group, odds ratio (OR) 1.84, 95% confidence interval (CI, 0.85, 3.98). The OR for the risk of non-ankle-specific AE versus no AE was 0.96, 95% CI (0.57, 1.61) for those receiving arthrodesis compared to arthroplasty. Compared to patients with no AEs, those experiencing ankle-specific AEs had significantly less improvement in Foot and Ankle Ability Measure Sports and activities of daily living (ADL) subscores and worst pain outcomes; however, both groups improved significantly in all measures except mental health. CONCLUSIONS: Ankle-specific AEs were infrequent and only weakly associated with operative procedure. Although patients improved in all functional outcomes except mental health, regardless of AE occurrence, ankle-specific AEs negatively impacted patient improvement compared to those with no AEs or a nonankle AE. The logistical effort and cost of tracking nonankle AEs does not seem to be justified. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Midshaft metatarsal segmental osteotomy with open reduction and internal fixation.

BACKGROUND: Metatarsalgia is a common source of patient discomfort and has multiple etiologies. Lesser metatarsal osteotomy is a recognized treatment modality for persistent symptoms after conservative care, yet the location and type of osteotomy remain highly debated topics. The current investigation reports the initial results regarding midshaft, segmental osteotomy of the lesser metatarsals with open reduction and internal fixation. METHODS: Ninety-five consecutive patients had lesser metatarsal midshaft, segmental osteotomy with open reduction and internal fixation from June, 1999, to October, 2001, representing 102 feet and 126 osteotomies. Patient records were retrospectively reviewed for osteotomy union, symptomatic relief, and complications associated with this procedure. Followup ranged from 5 months to 18 months with an average of 8.8 months. Fixation was achieved with a four-hole, 1/4-tubular, minifragment, plate and four 2.7-mm cortical screws. RESULTS: Five patients had transfer lesions, (five feet, five osteotomies) within the followup period. One patient (one foot, one osteotomy, 0.8%) developed a nonunion. After hardware removal this patient's osteotomy united. This technique produced excellent metatarsal union rates (125 of 126 osteotomies, 99.2%). CONCLUSIONS: Although further clinical investigation regarding patient outcome from this procedure needs to be carried out, the data from this preliminary study indicate that midshaft segmental osteotomy of a lesser metatarsal is a useful technique for metatarsal shortening with a high rate of bony union.

Heel overload associated with heel cord insufficiency.

BACKGROUND: Heel cord lengthening is a common component of foot and ankle surgery. If the tendon is anatomically or functionally over lengthened patients may develop plantarflexion weakness and heel overload problems such as symptomatic plantar heel callosities and heel ulceration. METHODS: Nine patients who developed heel overload or heel ulcer after a heel cord lengthening or an irreparable rupture were identified. Initial foot injury, risk factors, treatment, and followup were reviewed. RESULTS: Five of the nine patients had diabetes and an insensate heel. The ulcer healed in two of five patients with a dorsiflexion stop brace, two with a tendon transfer, and one required a below knee amputation. There were four patients with heel overload with normal sensation and no diabetes. One improved with strengthening exercises, two with tendon transfer, and one required a below knee amputation. CONCLUSIONS: Heel cord insufficiency can lead to an overload callus or a heel ulcer. Patients with diabetes and an insensate heel are at highest risk, but this problem also can occur in patients with normal sensation. Obesity and ipsilateral first toe amputation also may be risk factors.

Randomized prospective study comparing tri-cortical iliac crest autograft to allograft in the lateral column lengthening component for operative correction of adult acquired flatfoot deformity.

BACKGROUND: Operative treatment of stage II posterior tibial tendon insufficiency (PTTI) is controversial. Many soft-tissue and bony procedures and various combinations of the two have been reported for treatment of stage II PTTI. Orthopaedists recognize the lateral column lengthening component of the procedure as a successful reconstructive technique. The use of cortical allograft for lateral column lengthening in the correction of pes planus in the pediatric patient population has been routine. In the adult population, however, tricortical iliac crest autograft has been the bone graft of choice. Harvest of this autograft can precipitate significant morbidity and cost. Therefore, we undertook this randomized controlled trial to compare graft incorporation and healing of allograft and autograft in the lateral column lengthening component of adult flatfoot reconstruction. METHODS: Lateral column lengthening was done as a component of operative correction for stage II PTTI in adult patients (older than 18 years) by two surgeons using similar procedures. The patients were randomized to either the allograft or autograft procedures. The primary endpoint was graft incorporation and healing as assessed by radiographs. RESULTS: The study included 33 randomized feet in 31 patients. We followed 18 feet in the allograft group and 15 in the autograft group to the point of union. There were 21 women and 10 men. There were no delayed unions, nonunions, or hardware failures. All patients in both groups achieved bony union by the 12-week followup evaluation. Two superficial foot infections were successfully treated with oral antibiotics. Two patients in the autograft group continued to have hip donor site pain at 3 months. CONCLUSIONS: This study suggests that union rates of allograft and autograft (iliac crest bone graft) are equal. The use of allograft in the lateral column lengthening component of operative correction of adult stage II PTTI appears to be a viable alternative to the use of iliac crest autograft and eliminates the morbidity and increased cost associated with autograft harvest.