Republication of "Congenital Dislocation of the Fifth Metatarsophalangeal Joint in Adults: Operative Technique".

Congenital dislocation of the fifth metatarsophalangeal (MTP) joint can cause significant limitations in a patient's ability to wear a closed shoe. Historic treatment has involved amputation of the digit or attempts at reconstruction. These techniques have had limited success with unreliable correction and/or unacceptable cosmesis. The authors present a detailed, methodical approach to reconstruction of this deformity with a stepwise algorithm that addresses both the bony and soft tissue components of the deformity. With this modern technique, reliable and satisfactory results can be expected.

Summary Report of the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society's Symposium on Targets for Osteoarthritis Research: Part 1: Epidemiology, Pathophysiology, and Current Imaging Approaches.

This first of a 2-part series of articles recounts the key points presented in a collaborative symposium sponsored jointly by the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society with the intent to survey the state of scientific knowledge related to incidence, diagnosis, pathologic mechanisms, and injection treatment options for osteoarthritis (OA) of the foot and ankle. A meeting was held virtually on December 3, 2021. A group of experts were invited to present brief synopses of the current state of knowledge and research in this area. Part 1 overviews areas of epidemiology and pathophysiology, current approaches in imaging, diagnostic and therapeutic injections, and genetics. Opportunities for future research are discussed. The OA scientific community, including funding agencies, academia, industry, and regulatory agencies, must recognize the needs of patients that suffer from arthritis of foot and ankle. The foot and ankle contain a myriad of interrelated joints and tissues that together provide a critical functionality. When this functionality is compromised by OA, significant disability results, yet the foot and ankle are generally understudied by the research community. Level of Evidence: Level V - Review Article/Expert Opinion.

Summary Report of the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society's Symposium on Targets for Osteoarthritis Research: Part 2: Treatment Options.

This second of a 2-part series of articles recounts the key points presented in a collaborative symposium sponsored jointly by the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society with the intent to survey current treatment options for osteoarthritis (OA) of the foot and ankle. A meeting was held virtually on December 10, 2021. A group of experts were invited to present brief synopses of the current state of knowledge and research in this area. Topics were chosen by meeting organizers, who then identified and invited the expert speakers. Part 2 overviews the current treatment options, including orthotics, non-joint destructive procedures, as well as arthroscopies and arthroplasties in ankles and feet. Opportunities for future research are also discussed, such as developments in surgical options for ankle and the first metatarsophalangeal joint. The OA scientific community, including funding agencies, academia, industry, and regulatory agencies, must recognize the importance to patients of addressing the foot and ankle with improved basic, translational, and clinical research. Level of Evidence: Level V, review article/expert opinion.

Preoperative Gait Analysis of Peroneal Tendon Tears.

BACKGROUND: Little is known regarding the impact of peroneal tendon tears on function. This study quantifies gait changes associated with operatively-confirmed peroneal tendon tears. METHODS: Sixty-five patients with unilateral peroneal tendon tears were prospectively evaluated using preoperative 3D multisegment gait analysis of both limbs. Data were analyzed according to pattern/severity of tears, as confirmed surgically: peroneus brevis tears, reparable (PBR); peroneus brevis tears, irreparable (PBI); peroneus longus tears, irreparable (PLI); and concomitant irreparable tears of both tendons (PBI+PLI). The following parameters were analyzed: ankle sagittal motion, coronal motion, axial rotation, foot progression angle, sagittal power, sagittal moment. RESULTS: Twelve patients (18.5%) had the PBR pattern, 37 (56.9%) PBI, 10 (15.4%) PLI, and 6 (9.2%) PBI+PLI. Compared with the contralateral, nonpathologic extremities, limbs with peroneal tears had diminished ankle sagittal motion (mean 23.14 vs 24.30 degrees, P = .012), ankle/hindfoot axial rotation (6.26 vs 7.23 degrees, P = .001), sagittal moment (1.16 vs 1.29 Nm/kg, P < .001), and sagittal power (1.24 vs 1.47 W/kg, P < .001). The most severe tear patterns had the greatest derangements in multiple parameters of gait (PBI+PLI > PBI or PLI > PBR). For example, all groups except PBR had loss of ankle sagittal moment and/or power in the affected limb, and the greatest losses in moment and power were in the PBI+PLI group (1.22 vs 0.91 Nm/kg, P = .003 for moment; 0.73 vs 1.31 W/kg, P < .001 for power). The PBI+PLI group had a >10-degree varus shift in coronal motion on the affected side (P = .002). CONCLUSION: This is the first study to demonstrate diminished biomechanical function in patients with peroneal tendon tears. In vivo 3-dimensional gait analysis found significant changes in hindfoot motion, ankle motion, and ankle power. Impairments were related to the pattern and severity of the tears, and demonstrated a strong association of peroneal tendon tears with diminished ankle plantarflexion strength. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Association of Cavovarus Foot Alignment With Peroneal Tendon Tears.

BACKGROUND: Although it is a widely accepted clinical principle that cavovarus deformity predisposes to peroneal tendon problems, there are limited data to support that assumption. This study tested the hypothesis that cavovarus is associated with peroneal tendon tears and evaluated which radiographic measures correlated with that association. METHODS: A retrospective comparison of radiographic measures of cavovarus in 234 consecutive patients operatively treated for chronically symptomatic peroneal tendon tears was compared to a matched control group. Measures included calcaneal pitch, anteroposterior (AP) talometatarsal and talocalcaneal angles, and talonavicular coverage angle. A novel coordinate system analyzed midfoot and hindfoot components of cavovarus. Analysis of variance was used to compare cohorts, and a Tukey-Kramer test used to analyze 3 subgroups of brevis and longus tears, and concomitant tears. RESULTS: The distribution of tears was 73% peroneus brevis, 8% longus, and 19% both tendons. Compared with controls, the study group, and subgroups, had multiple measures of increased cavovarus, including greater calcaneal pitch (P = .0001), decreased AP talo-first metatarsal angle (P = .0001), and increased talonavicular coverage angle (P = .0001). Elevated medial longitudinal arch, and rotational changes in the radiographic profiles of the hindfoot were found with the coordinate system described by Yokokura. CONCLUSION: This study found a statistically significant association of increased cavovarus deformity with peroneal tendon tears, compared to controls. It documented the relative incidence of tears of peroneus brevis, peroneus longus, and concomitant tears in a large surgical series. It demonstrated which simple radiographic angles and complex coordinate measurements of cavovarus deformity were significantly associated with peroneal tendon tears. LEVEL OF EVIDENCE: Level III, retrospective comparative cohort study.

Long-term Functional Results of Total Ankle Arthroplasty in Stiff Ankles.

BACKGROUND: Total ankle arthroplasty (TAA) is advocated over ankle arthrodesis to preserve ankle motion (ROM). Clinical and gait analysis studies have shown significant improvement after TAA. The role and outcomes of TAA in stiff ankles, which have little motion to be preserved, has been the subject of limited investigation. This investigation evaluated the mid- to long-term functional outcomes of TAA in stiff ankles. METHODS: A retrospective study of prospectively collected functional gait data in 33 TAA patients at a mean of 7.6 (5-13) years postoperatively used 1-way analysis of variance and multivariate regression analysis to compare among preoperative and postoperative demographic data (age, gender, body mass index, years postsurgery, and diagnosis) and gait parameters according to quartiles of preoperative sagittal ROM. RESULTS: The stiffest ankles had a mean ROM of 7.8 degrees, compared to 14.3 degrees for the middle 2 quartiles, and 21.0 degrees for the most flexible ankles. Patients in the lowest quartile (Q1) also had statistically significantly lower step length, speed, max plantarflexion, and power preoperatively. Postoperatively, they increased step length, speed, max plantarflexion, and ankle power to levels comparable to patients with more flexible ankles preoperatively (Q2, Q3, and Q4). They had the greatest absolute and relative increases in these parameters of any group, but the final total ROM was still statistically significantly the lowest. CONCLUSION: Preoperative ROM was predictive of overall postoperative gait function at an average of 7.6 (range 5-13) years. Although greater preoperative sagittal ROM predicted greater postoperative ROM, the stiffest ankles showed the greatest percentage increase in ROM. Patients with the stiffest ankles had the greatest absolute and relative improvements in objective function after TAA, as measured by multiple gait parameters. At intermediate- to long-term follow-up, patients with stiff ankles maintained significant functional improvements after TAA. LEVEL OF EVIDENCE: Level III, comparative study.

Correlation of Patient-Reported Outcomes With Physical Function After Total Ankle Arthroplasty.

BACKGROUND: Total ankle arthroplasty (TAA) is successful by both subjective patient-reported outcome measures (PROMs) and objective functional improvements of gait. Each is reproducible and valid, but they are entirely distinct methods. This study investigated the correlation between subjective and objective outcomes of TAA. METHODS: Seventy patients underwent gait analysis preoperatively and 1 year after TAA. The 36-Item Short-Form Health Survey (SF-36) and visual analog score (VAS) for pain and American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scores were recorded at each interval. A Student t test, a multivariate regression, and a Pearson correlation coefficient were used to measure the correlation between parameters of gait and PROMs. RESULTS: Patients had statistically significant improvements in gait velocity, total range of motion (ROM), maximum plantarflexion, ankle power, and SF-36 Physical, VAS, and AOFAS scores. The SF-36 Physical score had a moderate positive correlation with preoperative walking speed, step length, and ankle power and postoperative walking speed and ankle power. No correlation between VAS score and function was detected. The AOFAS score had a moderate positive correlation with postoperative walking speed, step length, and ankle power, and improvement in walking speed, cadence, and ankle power. CONCLUSION: Statistically significant correlations were found between numerous preoperative and postoperative comparisons of PROMs and the AOFAS score with the objective biomechanical outcomes of gait. Walking speed and ankle push-off power correlated most with patient perceptions of function and improvement, while pain and ROM did not. Subjective PROMs and objective biomechanical outcomes were complementary in the assessment of surgical outcomes and, combined, helped to address the dilemma of the confounding effect of other lower extremity pathologies on PROMs. LEVEL OF EVIDENCE: Level III, comparative series.

Functional Outcomes of Total Ankle Arthroplasty at a Mean Follow-up of 7.6 Years: A Prospective, 3-Dimensional Gait Analysis.

BACKGROUND: In vivo gait analysis provides objective measurement of patient function and can quantify that function before and after ankle reconstruction. Previous gait studies have shown functional improvement for up to 4 years following total ankle arthroplasty (TAA), but to date, there are no published studies assessing function at ≥5 years following TAA. We hypothesized that patients who underwent TAA would show significant improvements in walking function at a minimum follow-up of 5 years, compared with their preoperative function, as measured by changes in temporospatial, kinematic, and kinetic gait parameters. METHODS: Three-dimensional gait analysis with a 12-camera digital motion-capture system and double force plates was utilized to record temporospatial, kinematic, and kinetic measures in 33 patients who underwent TAA with either the Scandinavian Total Ankle Replacement (Stryker; n = 28) or Salto Talaris Ankle (Integra LifeSciences; n = 5). Gait analysis was performed preoperatively and at a minimum follow-up of 5 years (mean, 7.6 years; range, 5 to 13 years). RESULTS: Significant improvements were observed in multiple gait parameters, with temporospatial increases in cadence (+9.5 steps/min; p < 0.0001), step length (+4.4 cm; p = 0.0013), and walking speed (+0.2 m/s; p < 0.0001), and kinematic increases in total sagittal range of motion (+2.0°; p = 0.0263), plantar flexion at initial contact (+2.7°; p = 0.0044), and maximum plantar flexion (+2.0°; p = 0.0488). Kinetic analysis revealed no loss of peak ankle power, despite patients aging. CONCLUSIONS: To our knowledge, this is the first study to report 7-year functional outcomes of TAA, quantified by objective, in vivo measurements of patient gait. Patients were shown to have sustained improvement in multiple objective parameters of gait compared with preoperative function. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Arthrodesis of Ipsilateral Hallux Metatarsophalangeal and Interphalangeal Joints.

BACKGROUND: Arthrodesis of the ipsilateral hallux metatarsophalangeal (MTP) and interphalangeal (IP) joints may be required for severe arthritis or deformity at both joints. The purpose of this study was to review outcomes of ipsilateral first MTP and IP joint arthrodesis. METHODS: Twenty feet were identified, for which the diagnosis was rheumatoid arthritis in 14, failed hallux valgus surgery in 5, and hallux rigidus in 1. The IP arthrodesis was performed first in 6 feet; MTP first in 8 feet; and both joints simultaneously in 6 feet. Median follow-up was 28 months (range 12-94). Medical records and radiographs were reviewed. American Orthopaedic Foot & Ankle Society (AOFAS) score and patient satisfaction were determined. RESULTS: Although all of the MTP arthrodeses healed, 8 of 20 feet (40%) failed to heal at the IP arthrodesis. The rate of IP nonunion was 17% (1/6) with IP arthrodesis first, 50% (4/8) with MTP arthrodesis first, and 50% (3/6) with simultaneous arthrodesis. Four of 8 IP nonunions were symptomatic. Subsequent surgery was required in 11 feet (55%), including repair of IP nonunion in 3 feet, hardware removal in 4, revision MTP malunion in 2, wound debridement in 1, and soft tissue reconstruction in 1. Median hallux AOFAS score for the cohort increased from 25 to 68. Eighteen feet resulted in patients who were very satisfied or satisfied with minor reservations. Neither AOFAS score nor satisfaction trended toward association with IP union. CONCLUSION: Ipsilateral arthrodesis of the hallux MTP and IP joints was challenging because of high rates of reoperation and IP nonunion, the latter of which was likely related to increased mechanical stress on the IP joint with immobilization of the MTP joint. Despite the high IP nonunion rate, IP nonunion did not predict patient-reported outcome. Fibrous ankylosis was an acceptable clinical outcome in many cases. LEVEL OF EVIDENCE: Level IV, case series.

Diagnosis and Operative Treatment of Peroneal Tendon Tears.

Peroneal tendon tears are a common but under-recognized source of ankle pain and dysfunction. Recognition of the characteristic symptoms, physical findings, and imaging results of peroneal tendon tears is essential for accurate diagnosis and appropriate treatment. Acute, limited tears of a single peroneal tendon may be debrided and repaired. However, by the time operative treatment is undertaken, many tears of a single tendon are sufficiently advanced that the surgeon may need to consider excision of the nonviable segment and tenodesis of the damged tendon to the to the adjacent peroneal tendon. Irreparable tearing of both peroneal tendons may be treated with flexor tendon transfer and/or allograft reconstruction. This review article focuses on diagnosis and operative treatment of peroneal tendon tears, including the treatment algorithms, operative technique, and published outcomes.

Acute Peroneal Injury.

A high clinical suspicion and greater understanding of the anatomy and pathophysiology of lateral ankle injuries have enabled early diagnosis and treatment-improving outcomes of acute peroneal tendon tears. Multiple conditions can be the cause of lateral ankle pain attributed to the peroneal tendons: tenosynovitis, tendinosis, subluxation and dislocation, stenosing tenosynovitis, abnormality related to the os peroneum, as well as tears of the peroneal tendons. It is imperative for the clinician to maintain a high suspicion for peroneal tendon abnormality when evaluating patients with lateral ankle pain.

Radiographic Results and Return to Activity After Sesamoidectomy for Fracture.

BACKGROUND: Limited data are available comparing the results of lateral sesamoidectomy and medial sesamoidectomy for the treatment of fractures recalcitrant to nonoperative treatment interventions. The hypothesis of this study was that sesamoidectomy for either lateral or medial sesamoid fractures would not change radiographic alignment of the first ray given the use of identical reconstruction of the plantar plate, intersesamoid ligament, and plantar ligament complex at the time of surgery. METHODS: This retrospective cohort study compared the outcomes of 46 consecutive patients treated with sesamoidectomy (24 lateral, 22 medial). Patient demographics, mechanisms of injury, and outcomes were recorded. Preoperative, postoperative, and changes in both hallux valgus angle (HVA) and intermetatarsal angle (IMA) were measured. RESULTS: No statistically significant difference could be detected for age ( P = .577), sex ( P = .134), return to activity ( P = 1.000), likelihood to undergo the procedure again ( P = 1.000), orthotic use postoperatively ( P = 1.000), perioperative complications ( P = .497), duration of symptoms ( P = .711), or length of follow-up ( P = .609). While statistically significant changes in preoperative and postoperative alignment were detected for both medial and lateral sesamoidectomy, these changes were not clinically significant. Patients undergoing medial sesamoidectomy had higher preoperative and postoperative HVA and IMA compared with those undergoing lateral sesamoidectomy. Medial sesamoidectomy patients had a net increase in both HVA and IMA, while patients undergoing lateral sesamoidectomy had a net decrease in both HVA and IMA. CONCLUSION: Although statistically significant changes in both HVA and IMA were detected, these values were too small to be considered clinically significant. Patient outcomes did not differ between the 2 groups, and sesamoidectomy was used with low patient morbidity for both medial and lateral sesamoid fractures that failed to respond to nonoperative modalities. These data suggest that the underlying mechanics of the foot may be different in patients who sustain medial and lateral sesamoid stress injury, suggesting a possible etiologic difference between medial and lateral sesamoid injuries. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Role of Total Ankle Arthroplasty in Stiff Ankles.

BACKGROUND: The decision tree for the operative treatment of end-stage ankle arthritis involves either ankle arthrodesis (AA) or total ankle arthroplasty (TAA). Although both have documented success providing diminished pain, improved patient-centered outcomes, and improved objective measures of function, arthroplasty is unique in its ability to preserve motion at the tibiotalar joint. Arthroplasty procedures are normally thought of as a motion-sparing surgery rather than a motion-producing procedure, which may limit its success in patients with stiff ankles. Our hypothesis was that there would be improvements in parameters of gait even in patients with a low degree of preoperative total sagittal range of motion. METHODS: A retrospective review was conducted on patients who underwent total ankle arthroplasty with greater than 1-year follow-up. Seventy-six patients were available who underwent isolated TAA for end-stage ankle arthritis with greater than 1-year follow-up. Patient demographics and preoperative and postoperative gait analyses were evaluated. Using a linear regression model, the effect sizes for the variables of age, gender, BMI, preoperative diagnosis, and preoperative total sagittal range of motion were calculated. Multivariate analysis was used to determine the influence each individual variable had on the many parameters of preoperative gait, postoperative gait, and change in gait after surgery. A post hoc analysis was conducted in which patients were divided into 4 quartiles according to preoperative range of motion. A 1-way analysis of variance (ANOVA) was used to compare improvement in parameters of gait for the 4 subgroups. RESULTS: Although a greater degree of preoperative sagittal range of motion was predictive of greater postoperative sagittal range of motion, patients with limited preoperative range of motion experienced a greater overall improvement in range of motion, and clinically meaningful absolute improvements in range of motion, and other parameters of gait. The post hoc analysis demonstrated that patients in the lowest quartile of preoperative motion had both statistically and clinically significant greater improvements across numerous parameters of gait, although the absolute values were lower than in the patients with higher preoperative ROM. Age, gender, BMI, and preoperative diagnosis did not correlate with changes in parameters of gait after total ankle arthroplasty. CONCLUSION: Preoperative range of motion was predictive of overall postoperative gait function. On one hand, a low preoperative range of motion resulted in a lower absolute postoperative function. On the other hand, patients with stiff ankles preoperatively had a statistically and clinically greater improvement in function as measured by multiple parameters of gait. This suggests that total ankle arthroplasty can offer clinically meaningful improvement in gait function and should be considered for patients with end-stage tibiotalar arthritis even in the setting of limited sagittal range of motion. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Kinematics and Function of Total Ankle Replacements Versus Normal Ankles.

End-stage ankle arthritis produces severe functional disability, quantifiable by gait abnormalities. In all categories of gait parameters, total ankle arthroplasty (TAA) satistically significantly improves function, compared to patients' preoperative function. There are increases in step length, cadence and velocity; in sagittal plane motion of the ankle, as well has hip and knee motion, and in ankle power and moment. These functional gait improvements correspond to clinical improvements of pain relief and satisfaction. Although these improvements fail to reach the functional performance of healthy controls, the improvement over preoperative function is clinically meaningful and statistically significant.

Early radiographic and clinical results of Salto total ankle arthroplasty as a fixed-bearing device.

BACKGROUND: Total ankle replacement has increased in popularity in the management of severe tibiotalar arthritis. Most previous clinical reports focused on mobile-bearing designs. This study evaluates early radiographic and clinical results of the Salto fixed bearing design. METHODS: Twenty-three Salto fixed-bearing implants were prospectively studied. Records were reviewed for clinical outcome scores (VAS, AOFAS, SF36), subsequent surgeries, complications, radiographic data and implant survivorship. Average follow-up was 36 months. RESULTS: Statistically significant improvements in VAS, AOFAS ankle/hindfoot scores, and SF36 scores were shown at an average of 3 years postoperatively. At 3 years followup, survivorship of the implant was 82.6% with any reoperation as the endpoint and 95.6% for revision or removal of components. Seven patients had radiolucencies around the implant, one of which required revision to arthrodesis. CONCLUSION: The fixed-bearing Salto ankle replacement has comparable early radiographic and clinical results to reports of the mobile-bearing Salto of comparable followup. LEVEL OF EVIDENCE: Level IV.

Salvage of avascular necrosis of the talus by combined ankle and hindfoot arthrodesis without structural bone graft.

BACKGROUND: Osteonecrosis of the talus is a well-recognized pathology, which can result in significant hindfoot collapse resulting in poor function and pain. Treatment with intramedullary tibiotalocalcaneal arthrodesis (IMTCA) using a retrograde intramedullary nail is widely utilized for severe concomitant tibiotalar and subtalar pathologies. This study reports the results of ankle and hindfoot arthrodesis in patients with arthritis and deformity caused specifically by talar osteonecrosis. METHODS: Fourteen ankle and hindfoot arthrodeses with retrograde intramedullary nail were studied, with a mean follow-up of 26 months. Medical records were reviewed for operative technique, concomitant procedures, bone graft used, and postoperative complications including nonunion, infection, nerve injury, wound healing issues, and the need for additional surgeries. Clinical outcomes included Visual Analogue Scale for pain, the AOFAS Ankle/Hindfoot Score, and the SF-36 questionnaire. RESULTS: Over 80% of cases had osteonecrosis involving the entire body of the talus. In 4 cases tibiocalcaneal arthrodesis was performed, with the remaining talar head-neck portion fused to anterior aspect of tibia. Union was achieved in all cases. The mean preoperative VAS score was 6.9 (range 5 to 9, SD ± 1.5) decreasing to 1.7 (range 0 to 6, SD ± 2.2) postoperatively (P = .00008). The mean preoperative AOFAS score was 32.7 (range 20 to 46, SD ± 8.7), increasing to 72.1 (range 46 to 86, SD ± 10.1, P = .00003). The mean preoperative SF-36 physical component score was 30.5 (range 21 to 42, SD ± 6.9) increasing to 42.8 (range 20 to 60, SD ± 11.4) postoperatively (P = .02). Complications included 1 stress fracture, 4 hardware removals, and 1 superficial infection. CONCLUSION: Ankle and hindfoot arthrosis due to extensive talar AVN can be successfully treated with IMTCA.

Joint salvage after neglected intra-articular physeal fracture of the hallux in high-level gymnasts.

UNLABELLED: Chronic sports-related injuries involving the hallux are well known in adult populations. However, they are less frequently described in adolescents. We present 2 cases of elite-level gymnasts with neglected Salter-Harris IV fractures involving the proximal phalanx of the great toe following a severe hyperextension injury to the metatarsophalangeal joint. Both were successfully treated with open reduction and internal fixation with return to pre-injury level of activity, improvement in outcome scores, and demonstration of no disability from injury 2 years after surgical intervention. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case Series.

Improvement in gait following combined ankle and subtalar arthrodesis.

BACKGROUND: This study assessed the hypothesis that arthrodesis of both the ankle and the hindfoot joints produces an objective improvement of function as measured by gait analysis of patients with severe ankle and hindfoot arthritis. METHODS: Twenty-one patients with severe ankle and hindfoot arthritis who underwent unilateral tibiotalocalcaneal arthrodesis with an intramedullary nail were prospectively studied with three-dimensional (3D) gait analysis at a minimum of one year postoperatively. The mean age at the time of the operation was fifty-nine years, and the mean duration of follow-up was seventeen months (range, twelve to thirty-one months). Temporospatial measurements included cadence, step length, walking velocity, and total support time. The kinematic parameters were sagittal plane motion of the ankle, knee, and hip. The kinetic parameters were sagittal plane ankle power and moment and hip power. Symmetry of gait was analyzed by comparing the step lengths on the affected and unaffected sides. RESULTS: There was significant improvement in multiple parameters of postoperative gait as compared with the patients' own preoperative function. Temporospatial data showed significant increases in cadence (p = 0.03) and walking speed (p = 0.001) and decreased total support time (p = 0.02). Kinematic results showed that sagittal plane ankle motion had decreased, from 13.2° preoperatively to 10.2° postoperatively, in the operatively treated limb (p = 0.02), and increased from 22.2° to 24.1° (p = 0.01) in the contralateral limb. Hip motion on the affected side increased from 39° to 43° (p = 0.007), and knee motion increased from 56° to 60° (p = 0.054). Kinetic results showed significant increases in ankle moment (p < 0.0001) of the operatively treated limb, ankle power of the contralateral limb (p = 0.009), and hip power on the affected side (p = 0.005) postoperatively. There was a significant improvement in gait symmetry (p = 0.01). CONCLUSIONS: There was a small loss of sagittal plane motion in the affected limb postoperatively. There were marked increases in gait velocity, ankle moment, and hip motion and power, documenting objective improvements in ambulatory function. The data showed that preoperative ankle motion was greatly diminished. This may suggest that pain is more important than stiffness in asymmetric gait.

Charcot arthropathy of the foot and ankle in patients with idiopathic neuropathy.

BACKGROUND: Charcot neuroarthropathy in the developed countries is primarily associated with diabetic neuropathy. This study investigated a series of patients with Charcot arthropathy associated with idiopathic peripheral neuropathy to evaluate the natural history in these patients and to evaluate the efficacy of a treatment protocol used for diabetic Charcot joints. METHODS: The records and radiographs of patients with Charcot arthropathy of the foot and ankle treated between 1986 and 2009 were retrospectively reviewed. Patients with known causes of or risk factors for peripheral neuropathy were excluded, identifying 82 feet in 59 patients with idiopathic neuropathy. Twenty-three (39%) were bilateral. The average age was 76 years and the average follow-up was 60 months. Data were analyzed for medical history and diagnoses, medications, anatomic classification of Charcot arthropathy, history of ulcerations, ambulatory status, shoe wear and bracing, and operative interventions. Patient care was based on previous published treatment algorithms, based on conservative management with operative intervention reserved for nonhealing ulcers, infection, and/or nonplantigrade, unbraceable feet. Therapeutic success was a plantigrade foot with healed soft tissue envelope that allowed weight-bearing. RESULTS: In all, 55% involved the midfoot (type 1), 34% the hindfoot (type 2), and 11% the ankle, (type 3A). Seventy-one of 82 feet were successfully treated at the time of last follow-up. Thirty-six feet (43%) were treated nonoperatively with success in 33 (92%). Forty-six of 82 feet required operative intervention, with success at last follow-up in 38 (83%). There were 8 operative failures resulting in 2 transtibial amputations and 6 feet with persistent ulceration. CONCLUSIONS: This series of patients with Charcot arthropathy associated with idiopathic neuropathy demonstrated a wider spectrum of Charcot arthropathy of the foot and ankle than has been previously recognized or documented. At the present time, heightened awareness is needed to promote accurate diagnosis and appropriate treatment in nondiabetic patients with Charcot arthropathy. LEVEL OF EVIDENCE: Level IV, retrospective case series.