Tibialis Anterior Tendon Rupture Surgical Treatments and Outcomes: A Systematic Review and Meta-Analysis.

Tibialis anterior tendon ruptures are a rare condition with an often-delayed diagnosis due to transient pain and compensation of remaining anterior compartment tendons. Previous systematic reviews have limited their recommendations to surgical treatment over nonoperative cares given the relatively small sample size in the literature. This current systematic review and meta-analysis was performed to compare the outcomes amongst the various surgical techniques and define factors that may affect long term patients results. Twenty-six references (217 cases) were identified. Use of extensor tendon autograft (odds ratio [OR] 5.55; I2=46%), autograft repair through semitendinosus/gracilis/ plantaris/ Achilles tendon/ peroneus longus ([OR] 4.14; I2=71%), or direct repair ([OR] 3.59; I2=57%), provided the best postoperative outcomes, whereas allograft repair ([OR] .52; I2=77%),and ipsilateral split/ turn-down tibialis anterior tendon ([OR] .69; I2=71%), were associated with poorer outcomes. Ruptures fixed in the acute phase ([OR] 8.3; I2=26%), were associated with statistically significant better outcomes when compared to these ruptures fixed in the chronic phase ([OR] .52; I2=77%). Results of this systematic review and meta-analysis suggests that ruptures should be surgically repaired in the acute phase whenever possible and comparable outcomes can be achieved through extensor tendon autograft repair, autograft repair, and direct repair.

Union Rates and Complications of Lateral Column Lengthening Using the Interposition Plating Technique: A Radiographic and Medical Record Review.

Lateral column lengthening is a common procedure for correction of pes planovalgus. A tricortical bone graft has been a standard among foot and ankle surgeons. The purpose of the present study was to compare the union rates and complications between the 2 forms of fixation for lateral column lengthening. The present study was a retrospective medical record and radiograph review of 52 patients divided into 2 equal groups, allograft (group A) and opening wedge plate (group B). The radiographic analyses compared the preoperative, postoperative and long-term measurements of cuboid abduction and talonavicular angles. The outcome measures included nonunion, hardware removal, and infection. The median follow-up duration for each group was 34.5 (range 6.3 to 89.5) months and 12.6 (range 6.5 to 56.8) months for groups A and B, respectively. Group A had 4 nonunions (15.4%) and group B had 2 nonunions (7.7%). The mean radiographic measurements of cuboid abduction and talonavicular articulation for each group improved significantly. The incidence of hardware removal was greater for group A than for group B (30.8% versus 15.4%), although the difference was not statistically significant. The median time to osseous healing for group A was 12.0 (range 8.0 to 80.0) weeks and for group B was 10.0 (range 6.0 to 36.0) weeks. The interposition plating techniques for lateral column lengthening procedures had a lower nonunion rate and incidence of hardware removal compared with the traditional use of tricortical bone grafting. The findings from the present study will aid surgeons in alternative fixation for lateral column lengthening procedures.

Surgical Planning for Flexor Digitorum Longus Tendon Transfers: An Anatomic Study.

Posterior tibial tendon dysfunction is often coupled with various degrees of hindfoot valgus and equinus. Preoperative planning is essential to appropriate procedure choice and surgical efficiency. The purpose of the present study was to assess the anatomy at the harvest site for flexor digitorum longus tendon transfer, specifically at the master knot of Henry. Thirty fresh-frozen below-the-knee cadavers were used for dissection. A standard anatomic approach was performed for posterior tibial tendon debridement and flexor digitorum longus tendon transfer. The flexor digitorum longus tendon was harvested and measured at the master knot of Henry. The present anatomic study evaluated the tendon width of the flexor digitorum longus tendon at a common harvest site. Of the 30 specimens, 20 (67%) measured 5 mm and 10 (33%) measured 4 mm. A 5.0-mm interference screw would be acceptable in each specimen and therefore would be the safest choice. A 4.0-mm interference screw would be acceptable in only 33% of the specimens. Males have a slightly more robust flexor digitorum longus tendon than females at the harvest site. This information will assist surgeons in preoperative planning during stage II flatfoot correction for posterior tibial tendon dysfunction.

Anatomic Description of the Naviculocuneiform Articulation.

The naviculocuneiform articulation is composed of the navicular proximally and the 3 cuneiforms distally. It is not uncommon to perform surgical interventions at this joint for multiple pathologic foot etiologies. To date, no detailed anatomic measurement is available for each cuneiform articulation on the navicular. The purpose of the present study was to present an anatomic description of this complex joint to aid in better surgical understanding and improve surgical outcomes. Ten fresh, frozen, and thawed below-the-knee cadaveric specimens were used for anatomic dissection of the navicular and associated cuneiforms. The height and width were recorded across the largest span of the entire navicular-cuneiform joint complex and each facet. The mean navicular height and width was 19.9 mm and 34.7 mm, respectively. The medial cuneiform facet mean height and width was 19.9 mm and 15.8 mm, respectively. The intermediate cuneiform facet mean height and width was 20.4 mm and 16.9 mm, respectively. The lateral cuneiform facet mean height and width was 17.5 mm and 14.7 mm, respectively. A detailed description of this joint complex will aid foot and ankle surgeons in screw placement and surgical decision-making when performing complex medial column fusions. Advanced 3-dimensional weightbearing computed tomography would give us a better idea of the motion that occurs within this complex joint.

Posterior Ankle Structure Injury During Total Ankle Replacement.

Total ankle replacement studies have focused on reporting complications that are directly observed clinically or radiographically, including wound problems, technical errors, implant loosening, subsidence, infection, bone fractures, and heterotopic ossification. However, patients can still experience unresolved pain even when these problems have been ruled out. We initiated a study to more clearly define the relative risk of injury to the anatomic structures in the posterior ankle during total ankle replacement using a third-generation implant system. Ten fresh-frozen adult cadaveric below-the-knee specimens were positioned in the intraoperative positioning frame of an approved total ankle replacement system and adjusted to achieve proper foot alignment using fluoroscopic imaging. The relationship between the tibial cutting guide pins and the posterior neurovascular and tendon structures was measured using digital calipers. High rates of posterior structural injury were found. Nearly all proximal-medial pins encountered a posteromedial neurovascular structure, most commonly the tibial nerve. The distal-medial pins mainly encountered posteromedial tendinous structures, in particular, the flexor digitorum longus tendon. The proximal lateral pins were highly likely to encounter the Achilles tendon and the sural nerve. Our results support our hypothesis that the tibial neurovascular structures are at the greatest risk when preparing for and completing the bony resection, particularly with the medial and proximal cuts. Posterior ankle soft tissue structure injuries can occur during implantation but currently with unknown frequency and undetermined significance. Further study of posterior structural injuries could result in a more informed approach to post-total ankle replacement complications and management.

Anterior Approach Total Ankle Arthroplasty: Superficial Peroneal Nerve Branches at Risk.

In ankle arthroplasty, little attention has been given to intraoperative nerve injury and its postoperative sequelae. The aim of the present anatomic study was to determine the relationship of the superficial peroneal nerve to the standard anterior approach for total ankle arthroplasty. The superficial peroneal nerve was dissected in 10 below-the-knee cadaver specimens. The medial and intermediate dorsal cutaneous branches were identified. A needle was placed at the ankle joint. The following measurements were recorded: bifurcation into the medial and intermediate dorsal cutaneous branches, reference needle to the branches of the medial and intermediate superficial peroneal nerve, and the crossing branches of the medial dorsal cutaneous nerve. Two specimens (20%) had a medial dorsal cutaneous branch cross from medially to laterally. Eight specimens (80%) had a crossing branch of the medial dorsal cutaneous branch within 5 cm of the incision. No intermediate dorsal cutaneous branches were within the incision. The results from the present cadaver study suggest that during an anterior ankle approach, aberrant branches of the superficial peroneal nerve could require transection in 20% of patients at the joint level and ≤80% of patients with distal extension >35 mm from the ankle joint. The risk of injury to branches of the superficial peroneal nerve is substantial. The risk of nerve injury can be decreased with meticulous operative technique, smaller incisions, and the avoidance of aggressive retraction.

Symptomatic Hardware Removal After First Tarsometatarsal Arthrodesis.

Severe hallux valgus deformity with proximal instability creates pain and deformity in the forefoot. First tarsometatarsal joint arthrodesis is performed to reduce the intermetatarsal angle and stabilize the joint. Dorsomedial locking plate fixation with adjunctive lag screw fixation is used because of its superior construct strength and healing rate. Despite this, questions remain regarding whether this hardware is more prominent and more likely to need removal. The purpose of the present study was to determine the incidence of symptomatic hardware at the first tarsometatarsal joint and to determine the incidence of hardware removal resulting from prominence and/or discomfort. A review of 165 medical records of consecutive patients who had undergone first tarsometatarsal joint arthrodesis with plate fixation was conducted. The outcome of interest was the incidence of symptomatic hardware removal in patients with clinical union. The mean age was 55 (range 18.4 to 78.8) years. The mean follow-up duration was 65.9 ± 34.0 (range 7.0 to 369.0) weeks. In our cohort, 25 patients (15.2%) had undergone hardware removed because of pain and irritation. Of these patients, 18 (72.0%) had a locking plate and lag screw removed, and 7 (28.0%) had crossing lag screws removed. The fixation of a first tarsometatarsal joint fusion poses a difficult situation owing to minimal soft tissue coverage and the inherent need for robust fixation to promote fusion. Hardware can become prominent postoperatively and can become painful and/or induce cutaneous compromise. The results of the present observational investigation imply that surgeons can reasonably inform patients that the incidence of symptomatic hardware removal after first tarsometatarsal arthrodesis is approximately 15% within a median duration of 9.0 months after surgery.

Safety of achilles detachment and reattachment using a standard midline approach to insertional enthesophytes.

Detachment with reattachment of the Achilles tendon is a common surgery for debridement of retrocalcaneal exostosis, bursitis, and other insertional pathologic entities. The technique involves a midline skin incision on the posterior Achilles to the tendon. The distal Achilles attachment is removed in a U-shaped manner, leaving the medial and lateral flares, but exposing the posterior spur. This midline approach provides excellent exposure and allows for rapid and efficient surgical debridement. The tendon is reapproximated and repaired with a suture anchor to facilitate fixation to the posterior calcaneus. Some surgeons have expressed concerned that the rupture risk could be increased in the postoperative period using this technique. The present study was a retrospective medical record review of 98 patients (100 feet) who had undergone a midline approach with Achilles reattachment after insertional Achilles debridement during a 3-year period. The demographic and comorbidity data were collected and analyzed. The outcome measures were postoperative rupture and the need for revision surgery. The mean age was 51.9 years, and the patients included 59 females (60.2%) and 39 males (39.8%). The complications included 4 rupture or avulsion revisions (4.0%) and 2 recurrent pain and tendinitis revisions (2.0%). The most common repeat repair procedure included hardware removal and a flexor hallucis longus transfer or augmentation. Nine patients (9.0%) had wound complications, 7 (77.8%) of which necessitated incision and drainage. The midline approach with Achilles detachment and reattachment is a safe and effective method of surgical treatment of insertional Achilles pathologic entities. The low reoperation rate of 4.0% will allow foot and ankle surgeons to safely rely on this approach.

Enhanced Lapidus arthrodesis: crossed screw technique with middle cuneiform fixation further reduces sagittal mobility.

Persistent medial column sagittal mobility can be encountered despite successful first tarsometatarsal stabilization if fixation has been limited to the first tarsometatarsal joint. The purpose of the present cadaveric research was to quantify the effect of a third point of fixation from the base of the first metatarsal to the middle cuneiform compared with the traditional isolated first tarsometatarsal fixation. Ten matched pairs of below-the-knee specimens, with a known cause of death, sex, ethnicity, and age, height, weight, and body mass index at death, were used for our examination. Portable fluoroscopy aided with the accurate placement of all points of fixation. Measurements of movement were obtained using the validated Klaue device. The 20 matched below-the-knee specimens were from 10 cadavers (2 female and 8 male donors, aged 72.8 ± 9.3 years, body mass index 21.1 ± 4.2 kg/m(2)). The sagittal plane motion of the first ray was 7.45 ± 1.82 mm before fixation. With isolated first tarsometatarsal fixation, the sagittal motion decreased to 4.41 ± 1.51 mm and decreased further to 3.12 ± 1.06 mm, with the addition of middle cuneiform fixation. Statistically significant enhancement of the stability of sagittal first ray motion was noted with the addition of the first metatarsal to middle cuneiform pin, even after simulated Lapidus fixation. Our findings suggest that first metatarsal to middle cuneiform fixation can be beneficial if excessive sagittal motion is present after standard 2-point fixation and can play a role in the prevention of recurrence and complications.

Quantification of Subtalar Posterior Facet Involvement During Intramedullary Guidance of Total Ankle Arthroplasty:A Cadaveric Study.

Total ankle arthroplasty is an evolving treatment of ankle arthritis. One implant uses intramedullary guidance to enhance accuracy by accessing the tibial canal through the inferior aspect of the foot, potentially placing the subtalar joint articulation at risk. The purpose of the present cadaveric anatomic evaluation was to identify posterior subtalar articular facet joint involvement during intramedullary guidance to the tibial canal. Ten below-the-knee cadaveric specimens were used. After drilling into the tibial medullary canal with a 6-mm drill bit and using the standard targeting jig, the specimens were dissected, and the posterior facet was evaluated. We graded posterior facet involvement according to the location of the drill hole and, if within the facet, the percentage of the facet violated by the drill bit, with 100% representing the full circumference of the 6-mm drill bit. Of the 8 specimens in which the drill bit passed through the subtalar posterior articular facet, the encroachment was peripheral in all cases, with no specimen showing circumferential 6-mm drill bit articular penetration (no cases with 100%). Sinus tarsi penetration occurred in 20% of the cases. The dissections with articular involvement included 3 specimens with >50% of the drill bit penetrating and 5 with <50%. The portion of the posterior facet involved among the specimens that were violated was anterocentral in the joint. A risk of damage to the posterior facet of the subtalar joint exists with intramedullary total ankle systems. Our study has demonstrated that the drill bit will involve the anterocentral and anterolateral portions of the posterior facet of the subtalar joint, with <6 mm articular disruption in all cases.

Effect of Osteogenic Progenitor Cell Concentration on the Incidence of Foot and Ankle Fusion.

The use of biologics, namely demineralized bone matrix, bone marrow aspirate (BMA), and other growth factors, has gained popularity in foot and ankle surgery for use in compromised hosts or high-risk situations. Our research has shown the concentration of these pluripotent cells was greatest in the iliac crest. A medical record and radiographic review was performed to compare the effect of BMA harvest site osteogenic progenitor cells on the incidence of fusion. Radiographs were reviewed for radiographic evidence of trabecular bridging in 2 or more views. If fusion occurred, the number of osteogenic progenitor cells found in the combined BMA at surgery was recorded. A total of 33 patients were included in the present study. Of the 33 patients, 32 (97.0%) had radiographic fusion at a mean of 13 ± 6 (range 8 to 30) weeks, and 1 (3.0%) experienced nonunion and required revision. The patient procedures were as follows: 18 (54.5%) hindfoot arthrodeses, 8 (24.2%) forefoot arthrodeses, 4 (12.1%) fractures, and 3 (9.1%) isolated ankle fusions. The mean colony-forming units for the patients with fusion was 20.3 ± 23.5 (range 0.0 to 107.0). In the patient with nonunion, it was 0.20 colony-forming unit. Our comparison of the incidence of fusion with the use of osteogenic progenitor cells from 3 anatomic sites showed a low incidence of complications and a high incidence of fusion. No association was found between the BMA concentration and the incidence of fusion, suggesting a minimum concentration and biologic potential of pluripotent cells is necessary to achieve the clinical effect of fusion.

Safety analysis of cryopreserved amniotic membrane/umbilical cord tissue in foot and ankle surgery: a consecutive case series of 124 patients.

Cryopreserved amnion tissues derived from amniotic membrane/umbilical cord (AM/UC) have been used extensively in ophthalmology for minimizing postoperative inflammation, pain, and adhesion formation following various surgical procedures. There is limited data in the current literature regarding the use of amnion tissue product in foot and ankle surgery. The purpose of this retrospective study is to report the short-term safety profile after in vivo application of cryopreserved AM/UC tissue use in foot and ankle surgery. A retrospective consecutive case series was performed for cases where amnion tissue was used with a minimum follow-up of 120 days between 2011 and 2012. The clinical outcomes of interest were postoperative infections, delayed or nonhealing wounds, adverse surgical site reactions, and repeat surgery for formal irrigation and debridement. One hundred twenty-four patients qualified for inclusion. Cryopreserved AM/UC tissue was introduced into the surgical wound and placed adjacent to the compromised and repaired tendons, most frequently in peroneal and Achilles tendon repairs. In this level IV consecutive case series cohort, there was an overall wound complication rate of 5.64%, with a re-operation rate of 1.6% (2/124). In each of these cases, patients had an irrigation and debridement with ultimate successful wound healing. The results of this study demonstrate that the use of amnion tissue in the foot and ankle setting is safe with a decreasing trend in overall complication rates compared with historically published norms.

Updates on Total Ankle Arthroplasty.

The newer generation total ankle arthroplasty constructs afford higher levels of long-term survivability, and for the first in the history of ankle arthroplasty procedures, results are comparable to arthrodesis. Much of the success hinges on appropriate patient selection. A comprehensive workup of the patient will allow selection of adjunctive procedures as well as allowing for the determination of single versus 2-stage deformity correction. With the continual addition of implants, it is important to understand the specialization and indications that are assigned to certain models because this will help in selecting the most appropriate implant for any given patient.

Nonoperative Management of the Achilles Tendon Insertion.

Insertional Achilles tendinopathy can be a very challenging clinical syndrome with various nonoperative measures typically attempted before surgical intervention. Associated complications are known with surgical repair and can be limb altering. Owing to the longevity of clinical symptoms before clinical presentation, changing the pathophysiologic process and halting the inflammatory changes becomes paramount. Here we discuss nonoperative techniques and updates in the foot and ankle literature.

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.

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.

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.

Os Trigonum Syndrome.

This article offers an overview of os trigonum syndrome, complications, operative techniques, and the authors' preferred protocol. Os trigonum is an ossicle like many other ossicles in the foot and ankle. Individuals who require repetitive plantarflexion of the ankle for activity may develop symptoms of an enlarged os trigonum. Usually, symptoms will be isolated to the posteriolateral aspect of the ankle. Because of the normal anatomic route of the flexor hallucis longus tendon, its range of motion may also elicit pain to the posterolateral ankle. Conservative, as well as surgical including both endoscopic and open excision, has been described.

Charcot-Marie-Tooth type 1A with a pes planovalgus foot type: a case report.

UNLABELLED: The classic foot type of Charcot-Marie-Tooth type 1A is pes cavovarus with associated digital contractures. In this article, we describe a painful pes planovalgus foot type in a 10-year-old child with progressive Charcot-Marie-Tooth type 1A polyneuropathy. The authors discuss possible etiologies and treatment options in this isolated case. The value of gait analysis in preoperative planning and postoperative surveillance are also discussed. LEVEL OF CLINICAL EVIDENCE: 4.