Radiographic correction of stage III posterior tibial tendon dysfunction with a modified triple arthrodesis.

BACKGROUND: The literature supports fusion as the surgical treatment of choice for stage III posterior tibial tendon dysfunction (PTTD). The present study reports the radiographic correction following a modified triple arthrodesis (fusions of the subtalar, talonavicular, and first tarsometatarsal joints) in patients with stage III PTTD. METHODS: An institutional review board-approved retrospective study was performed to assess the radiographic outcome of a modified triple arthrodesis in 21 patients (22 feet). Pre- and postoperative weight-bearing radiographs were reviewed in a blinded fashion by clinicians of varying levels of training. The talo-first metatarsal, talocalcaneal, and talonavicular coverage angles were measured on anteroposterior views. On lateral views, the talo-first metatarsal (Meary's), talocalcaneal, calcaneal pitch, and talar declination angles and the medial cuneiform to floor distance were measured. Statistical analysis was performed to compare pre- and postoperative measurements, assess the degree of correction, and determine interobserver reliability of the radiographic measurements. RESULTS: All measurements improved significantly after treatment with a modified triple arthrodesis (P ≤ .001). The medial cuneiform to floor distance (0.910), talonavicular coverage angle (0.896), and lateral talo-first metatarsal angle (0.873) were the most reproducible between observers. Postoperatively, 100% of feet were corrected to normal medial cuneiform to floor distance and talonavicular coverage angle, and 90.9% were corrected to a normal lateral talo-first metatarsal angle. CONCLUSION: The modified triple arthrodesis resulted in a reliable and reproducible correction of the deformity seen in rigid stage III PTTD. LEVEL OF EVIDENCE: Level IV, case series.

Midline posterior approach to the ankle and hindfoot.

BACKGROUND: The posterior approach to the ankle and hindfoot can be used for fixation of fractures, fusions, or osteotomies and is especially useful in patients with poor soft tissue anteriorly, medially, or laterally. However, a high rate of wound complications has been reported with standard posterolateral and posteromedial approaches. Because of local wound problems with the standard approaches, we have used a midline posterior approach and a longitudinal midline splitting of the Achilles tendon. This approach provides excellent exposure while minimizing wound healing complications. This approach provides dissection between angiosomes, which should optimize preservation of the blood supply to the skin flaps. METHODS: We retrospectively evaluated wound healing in 33 consecutive patients who had surgery using the modified midline posterior approach. The mean age of the patients was 48 (range 16 to 83) years. The mean followup was 24 (range 12 to 73) months. Surgical procedures included ankle and pantalar arthrodeses (primary and revision), talectomies with tibiocalcaneal arthrodesis, repairs of fracture nonunions, reconstruction of a chronic Achilles rupture, and hardware removal with multiple debridements of chronic osteomyelitis. RESULTS: There were no instances of skin flap necrosis. One patient with diabetic neuropathic arthropathy developed a small superficial wound eschar that healed with dressing changes alone. Four patients developed deep infections; two of these had a history of deep infection and the other two had significant comorbidities. CONCLUSIONS: The modified midline posterior approach to the distal tibia, ankle, and hindfoot has a low primary wound complication rate without sacrificing exposure. This approach can be used for any procedure requiring posterior access to the distal tibia, ankle joint, or subtalar joint.

Radiographic Evaluation of Intermetatarsal Angle Correction Following First MTP Joint Arthrodesis for Severe Hallux Valgus.

BACKGROUND: Arthrodesis is a standard operative treatment for symptomatic arthritis of the first metatarsophalangeal (MTP) joint. Patients with degenerative joint disease (DJD), severe hallux valgus, and metatarsus primus varus may also require fusion of the first MTP joint. An important question in the latter group of patients is whether a proximal first metatarsal osteotomy is required, in addition to the first MTP joint fusion. Our hypothesis was that patients with severe hallux valgus and metatarsus primus varus, treated with first MTP joint arthrodesis alone, would have correction of the first-to-second intermetatarsal angle (1-2 IMA) and hallux valgus angle (HVA) to near population norms, without the addition of a proximal first metatarsal osteotomy. METHODS: Preoperative and postoperative radiographs of 19 feet, in 17 patients, with preoperative IMA greater than 15 were analyzed. Weight-bearing radiographs were divided into pre- and postoperative cohorts. Three independent reviewers measured these radiographs and mean 1-2 IMA and HVA were calculated. Mean follow-up was 10 months. RESULTS: The mean preoperative 1-2 IMA was 19.2 degrees (15.6-24.3). The mean preoperative HVA was 48.5 (36-56.6). The mean postoperative values for 1-2 IMA and HVA were 10.8 and 12.3 degrees, respectively. The mean change in IMA was 8.3 degrees and in the hallux valgus angle was 36.4 degrees. The differences between pre- and postoperative measurement for both angles were statistically significant (P < .001). Seven of 19 (37%) feet were corrected to an IMA of less than 9 degrees (normal), whereas in 15/19 feet the postoperative IMA was 12.3 degrees or less. The postoperative HVA was less than 15 degrees in 15/19 (79%) feet. CONCLUSION: This pre- and postoperative radiographic analysis of patients with severe bunion deformity demonstrated that HVA and 1-2 IMA were acceptably corrected without the addition of a proximal first metatarsal osteotomy. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Operative outcome of partial plantar fasciectomy and neurolysis to the nerve of the abductor digiti minimi muscle for recalcitrant plantar fasciitis.

A retrospective review was conducted of 23 patients (26 feet) to assess operative outcome of partial plantar fasciectomy and neurolysis to the nerve of the abductor digiti minimi muscle for recalcitrant plantar fasciitis. Nonsurgical treatment was implemented in all patients with no relief of symptoms (average 20.8 months) prior to surgery. Using a visual analog pain scale (0-10), the average preoperative pain was 9.2 (range, 8-10). Prior to surgery, 65.2% of patients had severe limitations of activity, and 34.8% of patients had moderate limitations of activity. An average 25.3-month follow-up (range, 8-51) was performed by telephone interview. Average postoperative pain decreased to 1.7 using the same visual analog scale. Thirteen patients (57%) had no functional limitations postoperatively and nine patients (39%) had minimal functional limitations postoperatively. One patient (4%) had moderate functional limitations postoperatively. Twenty patients (87%) were completely satisfied with the surgery, two patients (9%) were satisfied with reservations, and one patient (4%) was unsatisfied with the surgery. The average period before return to work or daily activities was 1.5 months. Two patients had minor complications of partial wound dehiscence that healed uneventfully and mild dorsal midfoot pain which required temporary use of a boot walker. While the majority of patients with plantar fasciitis can be managed with nonoperative treatment, those patients with recalcitrant plantar fasciitis can be effectively treated with partial plantar fasciectomy and neurolysis to the nerve of the abductor digiti minimi muscle.

Diabetic neuroarthropathy (Charcot joints): the importance of recognizing chronic sensory deficits in the treatment of acute foot and ankle fractures in diabetic patients.

Patients with diabetic neuropathy are at a higher risk of developing complications, especially Charcot arthropathy. Early diagnosis and intervention is the key to optimizing outcome. Therefore, diabetic patients with a lower extremity injury should be screened with sensory testing using a 5.07 monofilament.

Lateral ankle radiographs: do we really understand what we are seeing?

OBJECTIVES: To evaluate the validity of using lateral intraoperative fluoroscopic imaging to assess the reduction of the tibial plafond articular surface, two hypotheses were tested: 1) the distal tibial subchondral shadow on the lateral ankle radiograph is created equally by the medial, central, and lateral portions of the distal tibia; and (2) displacement of a 5-mm width osteochondral fragment is consistently recognizable on lateral fluoroscopic imaging. METHODS: Six human fresh-frozen tibial plafond cadaveric specimens were sagitally sectioned in 5-mm increments after removal of the anterior soft tissue and stabilization of the position of the ankle through external fixation. To test the first hypothesis, a perfect lateral radiograph was taken after sectioning the specimens. The sagittal sections were then removed sequentially from medial to lateral. A perfect lateral radiograph was taken after each change. The sagittal sections were then removed beginning laterally and moving medially. A perfect lateral radiograph was taken after each change. The images were then compared with specific evaluation of the change in the subchondral shadow density. To test the second hypothesis, three malreductions were created by displacing a 5-mm osteochondral segment. After each malreduction, a perfect lateral radiograph was saved. These saved fluoroscopic images were placed in random order with lateral images of normal specimens. Four experienced ankle surgeons were then asked to determine whether the radiographs revealed displacement. Inter- and intraobserver reliability was then evaluated. RESULTS: First, the subchondral shadow of the distal tibia appears to be created by an equal confluence of the subchondral bone of the medial, central, and lateral aspects of the tibial plafond. Second, fellowship-trained observers experienced in pilon fracture treatment correctly identified malreduction only 45% of the time. Intraclass correlation coefficient revealed very poor interobserver reliability with an alpha reliability statistic of 0.183. Intraobserver reliability across all four observers yielded an alpha statistic of 0.474, indicating inconsistencies in observers' evaluation of identical images at separate viewings. CONCLUSIONS: It is difficult to discern rotational or translational displacement of a 5-mm osteochondral fragment on a perfect lateral fluoroscopic view of the ankle. Even with what appears to be a perfect lateral fluoroscopic view intraoperatively, displacement may still be present. When small osteochondral fragments are present, direct visualization of the articular surface is necessary to confidently establish that an anatomic reduction has been achieved.