Anterior tibial tendon rupture: results of operative treatment.

BACKGROUND: Anterior tibial tendon ruptures are rare, and most studies have reported subjective outcome data, with little or no objective analysis. The purpose of this study was to review the results of the operative treatment of anterior tibial tendon ruptures using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale and objective isokinetic testing. METHODS: We retrospectively reviewed the results of operatively treated anterior tibial tendon ruptures in 10 patients. The average age at the time of surgery was 57 (18 to 79) years. The etiology of rupture was traumatic in five and spontaneous in five patients. Evaluation consisted of preoperative and postoperative questionnaires, physical examination, and isokinetic strength testing. Average time between surgery and isokinetic testing was 27.9 months. RESULTS: The average AOFAS score was 71.9 preoperatively and 89.8 postoperatively. Eight of 10 patients reported improvement in pain, and nine of 10 patients reported increased activity level postoperatively. All patients were satisfied with the overall function of their foot and would undergo the procedure again. The peak torque generated in the operative extremity during ankle dorsiflexion and hindfoot inversion was less than that of the uninvolved extremity. No statistically significant difference was noted between peak torque generation in ankles treated with direct anterior tibial tendon repair and ankles treated with anterior tibial tendon repair with augmentation. CONCLUSIONS: Operative treatment of anterior tibial tendon rupture resulted in a high level of patient satisfaction; however, isokinetic testing demonstrated a decrease in dorsiflexion and inversion strength compared to the uninjured extremity. The clinical significance of this residual weakness was not apparent in most patients. Patients with anterior tibial tendon ruptures should be forewarned that normal strength may not be a realistic expectation after surgery.

Total ankle arthroplasty with the Agility prosthesis: clinical and radiographic evaluation.

BACKGROUND: Although ankle arthrodesis remains a standard operative procedure for disabling ankle arthritis, it has potential long-term problems. Total ankle arthroplasty offers preserved joint motion and may be a more favorable option in select patients. The purpose of this study was to report the intermediate-term clinical and radiographic results of total ankle arthroplasty using the Agility prosthesis. METHODS: We retrospectively reviewed the results of total ankle arthroplasty in 41 consecutive patients (43 ankles). Evaluation included preoperative and postoperative questionnaires, physical examination, and radiographs. RESULTS: At the time of followup, 38 patients (40 ankles) were available for review. The most common preoperative diagnoses included posttraumatic arthritis (24 of 40 ankles, 60%) and rheumatoid arthritis (eight of 40 ankles, 20%). Average age at surgery was 63 (range 32 to 85) years. Average followup was 44.5 (range 26 to 64) months. Preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scores averaged 33.6 and 83.3, respectively, demonstrating significance (p < 0.001). Postoperative Medical Outcomes Study Short Form-36 (SF-36) Physical Component Summary (PCS) and Mental Component Summary (MCS) scores averaged 49.5 and 56.1, respectively. Although 34 of 40 ankles demonstrated radiographic lucency or lysis, the degree of involvement varied. Migration or subsidence of components was noted in 18 ankles. Overall, 37 of 38 patients were satisfied with the outcome of their surgery and would have the same procedure under similar circumstances. CONCLUSIONS: Agility total ankle arthroplasty results in a favorable clinical outcome and patient satisfaction in most patients at intermediate-term followup. However, total ankle arthroplasty is associated with potential complications and the need for subsequent operative intervention. Radiographic followup commonly reveals periprosthetic lucency, lysis, and component migration or subsidence, but this does not appear to adversely affect the intermediate-term clinical outcome. The long-term consequences of such radiographic findings are of concern, and surgeons and patients choosing this procedure need to be cautious.

The modified Lapidus procedure for hallux valgus: a clinical and radiographic analysis.

BACKGROUND: Historically, the modified Lapidus procedure has been considered technically challenging, with high rates of complications, including nonunion and malunion. The purpose of this study was to review the clinical and radiographic results of this technique for the treatment of hallux valgus associated with first ray hypermobility, specifically examining patient satisfaction and the incidence of complications. METHODS: We retrospectively reviewed the results of the modified Lapidus procedure in 32 patients (38 feet). Evaluation included preoperative and postoperative questionnaires, physical examination, and radiographs. RESULTS: Complete clinical data was available for 29 patients (35 feet) and complete radiographic data for 29 patients (34 feet). Average age at surgery was 54 (range 27 to 84) years. Average followup was 42 months (range 29 to 93) months. Average preoperative visual analog pain score was 7.2 and postoperative 2.3 (p < 0.001). Average preoperative AOFAS Hallux MTP-IP Score was 44.8 and postoperative 87.3 (p < 0.001). Average preoperative intermetatarsal (IM) angle was 16 degrees, and the hallux valgus (HV) angle was 34 degrees. Postoperatively, the average IM angle was 6 degrees, the HV angle 11 degrees. There were no cases of nonunion or malunion. Complications included symptomatic hallux varus in two, recurrence of hallux valgus deformity in one, deep venous thrombosis in one, and failure of fixation in one patient. Twenty-four percent of patients (7 of 29) noted the subjective sensation of midfoot stiffness and 34% (10 of 29) noted forefoot stiffness. None of these patients thought that the stiffness was a disability. Ninety percent of patients (26 of 29) were satisfied with their foot function, and 86% (25 of 29) were satisfied with the cosmetic appearance of their foot. CONCLUSIONS: The modified Lapidus procedure results in a satisfactory clinical outcome in most patients. With meticulous operative technique, rigid internal fixation, and strict postoperative weightbearing restrictions, successful union can be achieved and complications can be minimized. Care should be taken to avoid hallux varus, and patients need to be counseled regarding a potentially long convalescent period and possible postoperative stiffness.

Clinical outcome of surgical treatment of the symptomatic accessory navicular.

BACKGROUND: When conservative treatment fails to provide relief for a symptomatic accessory navicular, surgical intervention may be necessary. Numerous studies have been published, reporting the results of the traditional Kidner procedure and alternative surgical techniques, all of which produce mostly satisfactory clinical outcomes. The purpose of this study was to report the clinical results, utilizing the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Scale, of surgical management for symptomatic accessory navicular with simple excision and anatomic repair of the tibialis posterior tendon. METHODS: The authors retrospectively reviewed the results of 13 consecutive patients (14 feet) who underwent surgical treatment for symptomatic accessory navicular. The patients ranged in age from 16 to 64 years (average, 34.1 years; mean, 28.2 years) at the time of surgery. All patients had a type II accessory navicular. The average follow-up of the patients involved in the study was 103.4 months (range, 45-194 months). The AOFAS Midfoot Scale was utilized to determine both preoperative and postoperative clinical status of the 14 feet included in the study. RESULTS: The average preoperative AOFAS score was 48.2 (range, 20-75; mean, 38.8). The average postoperative AOFAS score was 94.5 (range, 83-100; mean, 94.3). At last follow-up, 13 of 14 feet were without any pain, no patients had activity limitations, and only two of 14 feet required shoe insert modification. Postoperatively, no patients had a clinically notable change in their preoperative midfoot longitudinal arch alignment. All of the patients in the study were satisfied with the outcome of their surgery and would undergo the same operation again under similar circumstances. CONCLUSIONS: When conservative measures fail to relieve the symptoms of a painful accessory navicular, simple excision of the accessory navicular and anatomic repair of the posterior tibialis tendon is a successful intervention. Overall, the procedure provides reliable pain relief and patient satisfaction. In the current study, the clinical status of each patient improved significantly postoperatively, quantified utilizing the AOFAS Midfoot Scale.

Clinical outcome of tibiotalar arthrodesis utilizing the chevron technique.

Tibiotalar arthrodesis remains the gold standard reconstructive procedure for the treatment of disabling ankle arthritis. The purpose of this study was to review the clinical results of tibiotalar arthrodesis utilizing the chevron fusion technique. The results of 46 consecutive patients who underwent ankle arthrodesis utilizing the chevron technique were reviewed. The etiology of the tibiotalar arthritis was posttraumatic in 29 of 46 patients. Of the remaining 17 patients, seven had osteoarthritis, five had talar osteonecrosis, two had rheumatoid arthritis, one had hemophilic arthropathy, one had gouty arthropathy, and one had unrecognized chronic osteomyelitis. Three patients had prior hindfoot arthrodeses, and two patients had bilateral ankle fusions at last follow-up. All patients were followed for a minimum of 2 years. Of the 46 patients, 41 were available for review, with an average follow-up of 7.3 years (range, 2-20 years). Twelve patients had greater than 10-year follow-up. The Mazur ankle score was calculated for all 41 patients. The average Mazur ankle score for the 41 patients available for review was 72.8, out of a maximum possible score of 90. Eighteen patients had excellent results, 11 patients had good results, five patients had fair results, and seven patients had poor results. The most common reasons for fair or poor results were symptomatic subtalar arthritis and multiple medical comorbidities. All patients with postoperative symptomatic subtalar arthritis had preoperative radiographic evidence of subtalar arthrosis. Of the 12 patients with greater than 10-year follow-up, nine had excellent or good results, and an average Mazur ankle score of 76.6. All patients with either prior hindfoot arthrodeses or bilateral ankle fusions had excellent or good results. Of the 41 arthrodeses included in the study, 38 (38/41, 93%) went on to clinical and radiographic union. The chevron technique provides a predictable method to obtain fusion of the tibiotalar joint. Most patients can expect excellent or good results. In the current study, 90% (37/41) of patients were satisfied with the outcome of their surgery and would undergo the same operation again under similar circumstances.