Short-term Results of Hemiarthroplasty of the Ankle Joint for Talar-Sided Cartilage Loss.

Background: Ankle hemiarthroplasty is a 1-piece implant system replacing the talar side of the tibiotalar joint. Hemiarthroplasty offers limited bone resection and may provide easier revision options than joint-ablating procedures. Methods: Prospective, multicenter, noncomparative, nonrandomized clinical study with short term follow-up on patients undergoing hemiarthroplasty of the ankle. Radiologic and functional outcomes (Foot and Ankle Outcome Score FAOS, Foot and Ankle Ability Measure [FAAM], Short Form-36 Health Survey [SF-36], Short Musculoskeletal Functional Assessment [SMFA], and visual analog scale [VAS] pain scores) were obtained at 3 and 12 months and the last follow-up (mean 31.9 months). Results: Ten patients met the inclusion criteria. Three were converted to total ankle replacement at 14, 16, and 18 months. Pain VAS scores improved on average from 6.8 to 4.8 (P = .044) of the remaining 7 at a mean of 31.9 months' follow-up. For these 7 in the Survival Group, we found that SF-36 physical health component improved from 25.03 to 42.25 (P = .030), SMFA dysfunction and bother indexes improved from 46.36 to 32.28 (P = .001), and from 55.21 to 30.14 (P = .002) in the Survival Group, and FAAM sports improved from 12.5 to 34.5 (P = .023). Conclusion: Patients undergoing hemiarthroplasty of the ankle joint for talar-sided lesions had a 30% failure rate by 18 months. Those who did not have an early failure exhibited modest pain reduction, functional improvements, and better quality of life in short-term follow-up. This procedure offers a possible alternative for isolated talar ankle cartilage cases. Level of Evidence: Level IV, prospective case series.

Cross-cultural adaptation and validation of the Short Musculoskeletal Function Assessment (SMFA) into Spanish (Chile).

The purpose of this protocol was to adapt and validate the English version of the Short Musculoskeletal Function Assessment (SMFA) into Chilean Spanish according to the World Health Organisation guidelines. This is a cross-sectional study of 897 surveys of patients with non-traumatic surgical orthopaedic pathologies. We analysed internal consistency, validity, and acceptability, including correlation with the short form 36 (SF-36) medical score. The validation included 900 participants with a response rate of 99,66%, with excellent internal consistency (Cronbach's α = 0.962). The Dysfunction and Bother Index items showed a value of 0.952 and 0.884 respectively, eliminating one item in the Dysfunction sub-scale. The principal component analysis was forced to four factors explaining 55.5% of the variance. SMFA-CL sub-scales are significantly correlated with SF-36 components and subcomponents. The first version of the SMFA-CL version (Spanish-Chilean) scale is reported. This culturally adapted score demonstrated a high rate of reliability, validity, and ability to objectively evaluate foot and ankle pathologies.

Restoration of Anatomic Parameters and Syndesmotic Reduction After Intramedullary Nailing of Distal Fibular Fractures.

Background: Intramedullary nailing of the fibula (FN) is a method of fixation that has proven to be useful for treating distal fibular fractures (DFs). FN minimizes soft tissue complications and provides similar stability to plating, with fewer hardware-related symptoms. Nevertheless, FN has been associated with syndesmotic malreduction and the incapacity of restoring length and rotation of the fibula. We aimed to evaluate the fibular position and syndesmotic reduction after fixation with FN compared with the uninjured ankle in the immediate postoperative period. Methods: Prospective cohort study. Patients with DF fractures treated with IN between January 2017 and January 2020 were included. Immediate postoperative bilateral ankle CT was obtained in all cases. Fibular rotation, length, and translation as well as syndesmotic diastasis were measured on both ankles and compared by 3 independent observers. Results: Twenty-eight patients were included (16 women). The mean age was 46 years (range 16-91). Fracture type distribution according to AO/ASIF classification included 19 patients with 44.B (67.9%), 8 patients with 44.C (28.6%), and 1 patient with a 44.A fracture (3.6%). No significant differences were identified considering fibular rotation (P = .661), syndesmotic diastasis (P = .147), and fibular length (P = .115) between the injured and uninjured ankle. Fibular translation had statistical differences (P = .01) compared with the uninjured ankle. The intraclass correlation coefficient showed an excellent concordance between observers except for fibular translation on the injured ankle. Conclusion: In this cohort, fixation of DF fractures with FN allows restoration of anatomical parameters of the ankle in terms of fibular rotation, length, and syndesmotic diastasis. However, fibular translation had significant differences compared with the uninjured ankle based on bilateral CT scan evaluation. Level of Evidence: Level II, prospective cohort study.

One-Stage Lengthening and Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy (DMMO) for Brachymetatarsia.

Level of Evidence: Level V.

Cross-cultural adaptation and validation of the Foot and Ankle Outcome Score (FAOS) into Spanish (Chile).

PURPOSE: To adapt and validate the English version of the Foot and Ankle Outcome Score (FAOS) into Spanish FAOS-CL, following the WHO guidelines. METHODS: A cross-sectional study including 318 outpatients with non-traumatic conditions. Validity, acceptability and internal consistency including correlations with the Medical Outcome Study Short Form 36 are reported. RESULTS: The preliminary version resulted from the forward and back-translation and a pilot administration. Validation response rate was 99.22%. Substantial ceiling effects were observed for Symptoms and ADL and floor effect for QoL sub-scales. The FAOS-CL had excellent internal consistency (Cronbach's α = 0.98). The principal component analysis gave five factors explaining the 72.6% of the variance. The FAOS-CL items significantly correlate with their sub-scales. FAOS-CL sub-scales significantly correlated with SF-36 components and subcomponents. CONCLUSION: The first Spanish version of the FAOS was generated. Culturally adapted and validated with high reliability capable of evaluating different foot and ankle conditions.

Isolated Subtalar Arthrodesis for Avascular Necrosis of the Talus.

Isolated subtalar arthrodesis has been attempted in talar avascular necrosis (AVN) patients to preserve the tibiotalar joint and potential revascularization. This article reports the efficacy of isolated subtalar arthrodesis in the setting of AVN. A retrospective review of subtalar arthrodeses was performed on a cohort of 12 patients with talar AVN who underwent subtalar arthrodesis. The primary outcome was radiographic fusion with secondary outcomes of subsequent procedures, recurrent pain, and perioperative complications. Radiographic fusion of subtalar arthrodesis occurred in 12 of 12 patients. Five of six patients with traumatic etiology went on to have secondary procedures. One of six patients with atraumatic etiology underwent a secondary procedure for advancement of tibiotalar arthritis. In the setting of atraumatic talar AVN, this small cohort demonstrates that isolated subtalar arthrodesis is a safe and reliable procedure with high fusion rates and low need for secondary procedures. (Journal of Surgical Orthopaedic Advances 28(2):132-136, 2019).

Knotless Modified Arthroscopic-Broström Technique for Ankle Instability.

Instability is a common sequela after repeated ankle sprains. When nonoperative treatment fails, open lateral ligament complex repair and reinforcement with the inferior extensor retinaculum has been the gold standard procedure. The recent advancements in arthroscopic techniques have created comparable biomechanical and functional results to open procedures. The authors' modification to the standard arthroscopic technique permits ligament approximation to the distal fibula over a larger surface area, using knotless anchors to avoid the need of an accessory portal and limit potential suture knot-related complications. Level of Evidence: Level V, expert opinion.

Technique tip: EDL-to-EHL double loop transfer for extensor hallucis longus reconstruction.

BACKGROUND: Extensor hallucis longus (EHL) tendon injuries often occur in the setting of lacerations to the dorsum of the foot. End-to-end repair is advocated in acute lacerations, or in chronic cases when the tendon edges are suitable for tension free repair. Reconstruction with allograft or autograft is advocated for cases not amenable to a primary direct repair. This is often seen in cases with tendon retraction and more commonly in the chronic setting. In many countries the use of allograft is very limited or unavailable making reconstruction with autograft and tendon transfers the primary choice of treatment. Tendon diameter mismatch and diminished resistance are common issues in other previously described tendon transfers. METHODS: We present the results of a new technique for reconstruction of non-reparable EHL lacerations in three patients using a dynamic double loop transfer of the extensor digitorum longus (EDL) of the second toe that addresses these issues. RESULTS: At one-year follow up, all patients recovered active/passive hallux extension with good functional (AOFAS Score) and satisfaction results. No reruptures or other complications were reported in this group of patients. No second toe deformities or dysfunction were reported. CONCLUSIONS: Second EDL-to-EHL Double Loop Transfer for Extensor Hallucis Longus reconstruction is a safe, reproducible and low-cost technique to address EHL ruptures when primary repair is not possible. LEVEL OF EVIDENCE: IV (Case Series).

Spring Ligament Instability.

The crucial role of the spring ligament complex within the pathologic process that leads to flatfoot deformity has evolved recently. There has been improvement in the anatomic knowledge of the spring ligament and understanding of its complex relationship to the deltoid complex and outstanding advances in biomechanics concepts related to the spring ligament. Optimization of flatfoot treatment strategies are focused on a renewed interest in the spring ligament and medial soft tissue reconstruction in concert with bony correction to obtain an adequate reduction of the talonavicular deformity and restoration of the medial longitudinal arch.

Treatment of postaxial polydactyly with plantar plate and medial collateral ligament reconstruction after supernumerary excision: A case report.

INTRODUCTION: Polydactyly is the most common congenital foot anomaly and consists of partial or complete duplication of a toe. Traditionally, surgical treatment has been amputation. There is little evidence when surgical treatment requires repairing the stabilizing structures of the metatarsophalangeal joint. OBJECTIVE: Assess the functional and radiologic outcomes of a case of postaxial polydactyly requiring plantar plate plate and medial collateral ligament reconstruction. METHODS: A 59-year-old female presented at clinic complaining from bilateral fifth toe polydactyly and metatarsalgia. A rudimentary extra toe with bony structures poorly developed was observed in the left foot. An excision was performed on the left foot. In the right foot, a fully developed extra digit was observed with medial and downwards deviation underneath the fourth metatarsal. RESULTS: Medial fifth-toe excision, plantar plate repair and medial collateral ligament reconstruction were performed due to malformation and widening of the distal surface of the plantar plate. Patient satisfaction and adequate functional status were observed at one-year follow-up. CONCLUSION: The plantar plate is the principal stabilizer of the MTP joint; therefore its reconstruction is of paramount importance for forefoot biomechanics.

Effectiveness of Allograft Reconstruction vs Tenodesis for Irreparable Peroneus Brevis Tears: A Cadaveric Model.

BACKGROUND: Irreparable peroneus brevis tendon tears are uncommon, and there is scant evidence on which to base operative treatment. Options include tendon transfer, segmental resection with tenodesis to the peroneus longus tendon, and allograft reconstruction. However, the relative effectiveness of the latter 2 procedures in restoring peroneus brevis function has not been established. METHODS: Custom-made strain gage-based tension transducers were implanted into the peroneus longus and brevis tendons near their distal insertions in 10 fresh-frozen cadaver feet. Axial load was applied to the foot, and the peroneal tendons and antagonistic tibialis anterior and posterior tendons were tensioned to 50% and 100% of physiologic load. Distal tendon tension was recorded in this normal condition and after sequential peroneus brevis-to-longus tenodesis and peroneus brevis allograft reconstruction. Measurements were made in 5 foot inversion/eversion and plantarflexion/dorsiflexion positions. RESULTS: Distal peroneus brevis tendon tension after allograft reconstruction significantly exceeded that measured after tenodesis in all tested loading conditions (P ≤ 0.022). With 50% of physiologic load applied, peroneus brevis tension was 1% to 28% of normal (depending on foot position) after tenodesis and 73% to 101% of normal after allograft reconstruction. Under the 100% loading condition, peroneus brevis tension was 6% to 43% of normal after tenodesis and 88% to 99% of normal after reconstruction with allograft. Distal peroneus longus tension remained within 20% of normal under all operative and loading conditions. CONCLUSION: Allograft reconstruction of a peroneus brevis tendon tear in this model substantially restored distal tension when the peroneal tendons and their antagonists were loaded to 50% and 100% of physiologic load. Tenodesis to the peroneus longus tendon did not effectively restore peroneus brevis tension under the tested conditions. CLINICAL RELEVANCE: Because tenodesis was demonstrated to be ineffective for restoration of peroneus brevis function, this procedure may result in an imbalanced foot clinically.

Systematic Quantification of Stabilizing Effects of Subtalar Joint Soft-Tissue Constraints in a Novel Cadaveric Model.

BACKGROUND: Distinguishing between ankle instability and subtalar joint instability is challenging because the contributions of the subtalar joint's soft-tissue constraints are poorly understood. This study quantified the effects on joint stability of systematic sectioning of these constraints followed by application of torsional and drawer loads simulating a manual clinical examination. METHODS: Subtalar joint motion in response to carefully controlled inversion, eversion, internal rotation, and external rotation moments and multidirectional drawer forces was quantified in fresh-frozen cadaver limbs. Sequential measurements were obtained under axial load approximating a non-weight-bearing clinical setting with the foot in neutral, 10° of dorsiflexion, and 10° and 20° of plantar flexion. The contributions of the components of the inferior extensor retinaculum were documented after incremental sectioning. The calcaneofibular, cervical, and interosseous talocalcaneal ligaments were then sectioned sequentially, in two different orders, to produce five different ligament-insufficiency scenarios. RESULTS: Incremental detachment of the components of the inferior extensor retinaculum had no effect on subtalar motion independent of foot position. Regardless of the subsequent ligament-sectioning order, significant motion increases relative to the intact condition occurred only after transection of the calcaneofibular ligament. Sectioning of this ligament produced increased inversion and external rotation, which was most evident with the foot dorsiflexed. CONCLUSIONS: Calcaneofibular ligament disruption results in increases in subtalar inversion and external rotation that might be detectable during a manual examination. Insufficiency of other subtalar joint constraints may result in motion increases that are too subtle to be perceptible. CLINICAL RELEVANCE: If calcaneofibular ligament insufficiency is established, its reconstruction or repair should receive priority over that of other ankle or subtalar periarticular soft-tissue structures.

Outcomes of Tibiotalocalcaneal Arthrodesis Through a Posterior Achilles Tendon-Splitting Approach.

BACKGROUND: A number of operative approaches have been described to perform a tibiotalocalcaneal (TTC) arthrodesis. Here we present the largest reported series of a posterior Achilles tendon-splitting approach for TTC fusion. METHODS: With institutional review board approval, a retrospective review of the TTC fusions performed at a single academic institution was carried out. Orthopedic surgeons specializing in foot and ankle surgery performed all procedures. Eligible patients included all those who underwent a TTC fusion via a posterior approach and had at least a 2-year follow-up. Forty-one patients underwent TTC arthrodesis through a posterior Achilles tendon-splitting approach. Mean age at surgery was 56.9±15.0 years. There were 21 female and 20 male patients. Preoperative diagnoses included arthritis (n = 13 patients), failed total ankle arthroplasty (9), avascular necrosis of the talus (9), prior nonunion of the ankle and/or subtalar joint (6), Charcot neuro-arthropathy (2), and stage IV flatfoot deformity (2). In 37 patients (90.2%), a hindfoot intramedullary arthrodesis nail was used, with posterior plate or supplemental screw augmentation in 17 patients. Posterior plate stabilization alone was utilized in 4 cases (9.8%). RESULTS: The fusion rate was 80.4%. Eight patients developed a nonunion of the subtalar, tibiotalar, or both joints. Complications were observed in 17 patients (41.4%). Of these, ankle nonunion (19.5%), tibial stress fracture (17%), postoperative cellulitis and superficial wound breakdown (9.7%), subtalar nonunion (4.8%), and TTC malunion (2.4%) were the most frequently identified. One patient eventually underwent amputation (2.4%). CONCLUSION: We believe that posterior Achilles tendon-splitting approach for tibiotalocalcaneal arthrodesis was a safe and effective method, with similar union and complications rates to some previously described techniques. We believe the posterior approach is advantageous as it provides simultaneous access to both the ankle and subtalar joints and allows for dissection to occur between angiosomes, which may preserve blood supply to the skin. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Tibiotalar Arthrodesis Conversion to Total Ankle Arthroplasty.

INTRODUCTION: Although conversion of the painful ankle arthrodesis to total ankle arthroplasty remains controversial, this surgical modality has satisfactorily expanded the treatment armamentarium for addressing this pathology. STEP 1 PREOPERATIVE PREPARATION AND SURGICAL PLANNING: Preoperative preparation and planning is similar to that for a primary total ankle arthroplasty, and implants designed for primary arthroplasty can be used in most patients managed with conversion to total ankle replacement. STEP 2 PATIENT POSITIONING: Position the patient as for a primary total ankle replacement. STEP 3 REMOVE HARDWARE AND INSERT PROPHYLACTIC MALLEOLAR SCREWS: Preserve exsanguination time by removing hardware prior to inflating the tourniquet. STEP 4 RECREATE THE TIBIOTALAR JOINT: Recreate the native joint line, which can be relatively easy in selected patients and challenging in others. STEP 5 SET THE OPTIMAL TALAR SLOPE: Set the optimal talar slope, which can be challenging, particularly when the ankle arthrodesis is malunited in equinus. STEP 6 RECREATE THE MEDIAL AND LATERAL GUTTERS: Because the former medial and lateral articulations between the talus and the malleoli can be difficult to define, use careful surgical technique to avoid compromise of the malleoli and excessive talar resection. STEP 7 MOBILIZE THE ANKLE AND USE BONE GRAFT IN DEFECTS FROM PREVIOUS HARDWARE: To avoid potential malleolar fractures, mobilize the ankle only after the prophylactic malleolar screws have been placed; the tibial and talar cuts, completed; the gutters, reestablished; all resected bone, removed; and scar tissue from the posterior aspect of the ankle, excised; thereafter, conversion total ankle arthroplasty is similar to a primary total ankle replacement, with the exception of potential bone defects where prior hardware was positioned. STEP 8 TALAR PREPARATION: Perform the routine steps for primary total ankle arthroplasty, often ignoring bone defects from the ankle arthrodesis hardware, but plan to repair the defects with bone-grafting before implanting the final talar component. STEP 9 TIBIAL PREPARATION AND DEFINITIVE COMPONENTS: Perform tibial preparation in a manner similar to that used for primary total ankle arthroplasty. RESULTS: We performed 23 conversion total ankle arthroplasties in patients who had an ankle arthrodesis, including those with pain despite successful fusion and those with painful nonunions9.

Conversion of Tibiotalar Arthrodesis to Total Ankle Arthroplasty.

BACKGROUND: Conversion of ankle arthrodesis to total ankle arthroplasty remains controversial. Although satisfactory outcomes have been published, not all foot and ankle surgeons performing total ankle arthroplasty have embraced this modality. METHODS: Twenty-three total ankle arthroplasties were performed in patients who had undergone a prior or an attempted ankle arthrodesis. The mean age at surgery was fifty-nine years (range, forty-one to eighty years), and the mean duration of follow-up was 33.1 months (minimum, twelve months). Indications for the procedure were symptomatic adjacent hindfoot arthritis (twelve patients) or symptomatic tibiotalar or subtalar nonunion (eleven) after tibiotalocalcaneal arthrodesis. We performed concomitant surgical procedures in eighteen ankles (78%), with the most common procedure being prophylactic malleolar fixation (70%). We prospectively evaluated clinical outcomes using the Short Form-36 (SF-36), Short Musculoskeletal Function Assessment (SMFA), and visual analog scale (VAS) for pain and assessed initial weight-bearing radiographs and those made at the most recent follow-up evaluation. RESULTS: The mean VAS pain score (and standard deviation) improved from 65.7 ± 21.8 preoperatively to 18.3 ± 17.6 at the most recent follow-up evaluation (p < 0.001), with five patients being pain-free (VAS score = 0). The mean SMFA bother and function indexes improved from 55 ± 22.9 and 46.7 ± 12.6 preoperatively to 30.6 ± 22.7 and 25.4 ± 17.4 at the most recent follow-up visit (p = 0.001 and p < 0.001, respectively). The mean SF-36 total score improved from 37.7 ± 19.3 to 56.4 ± 23.1 (p = 0.002). The implant survival rate was 87%. Four (20%) of the tibial components and fourteen (70%) of the talar components that were not revised exhibited initial settling and then were seen to be stabilized radiographically without further change in implant position. Three total ankle replacements (13%) showed progressive talar subsidence, prompting revision. Ten patients (43%) had minor complications not requiring repeat surgery. CONCLUSIONS: Short-term follow-up after conversion of ankle arthrodesis to total ankle arthroplasty demonstrated pain relief and improved function in a majority of patients. Patients who undergo this surgery frequently require concomitant procedures; we recommend prophylactic malleolar fixation when performing conversion total ankle arthroplasty. The rate of complications, particularly talar component settling and migration, is cause for concern. We do not recommend the procedure for ankle arthrodeses that included distal fibulectomy.

Evaluation of first metatarsal head declination through a modified distal osteotomy in hallux rigidus surgery. A cadaveric model.

BACKGROUND: First metatarsal osteotomies have been described for treatment of hallux rigidus. Most of these techniques result in declination of the first metatarsal head through shortening of the metatarsal and transfer metatarsalgia may result. Our objective was to evaluate the declination effect of a distal metatarsal osteotomy when different angulations and lateral translations are applied. MATERIALS AND METHODS: A cadaveric study was conducted performing a modified distal oblique osteotomy, which produces head declination while limiting shortening. Several transverse inclination angles (0-10-20-30-40°) were used. Thereafter, plantar translation of the metatarsal head was registered at different lateral displacements (1, 3, 5mm). RESULTS: Twenty-two specimens were included. Three feet were operated on with a 0° of angulation in the transverse plane, 6 with 10°, 5 with 20°, 5 with 30°, and 3 with 40°. Head declination significantly increased with higher angulation and with greater lateral translations (p<0.001), but the interrelationship between these two variables did not achieve statistical significance (p=0.597). In regards to angulation, significant differences in head declination were found between 0° (0.1-0.7 mm), 10°-20° (0.5-1.2mm) and 30°-40° (1.3-2.4mm). The metatarsal sesamoid joint was compromised when the osteotomy was performed at a 40° inclination angle. CONCLUSIONS: Metatarsal head declination is determined by the inclination angle of the oblique limb of the osteotomy and lateral displacement of the metatarsal head. Our results suggest that the effect of lateral displacement is an independent factor from angulation. The latter may impact surgery planning and may improve clinical outcome by selecting a safer inclination angle when lateral displacement of the metatarsal head is being considered. LEVEL OF EVIDENCE: Level II-A, systematic review with homogeneity of cohort studies.

Allograft reconstruction of peroneus longus and brevis tendons tears arising from a single muscular belly. Case report and surgical technique.

Anatomic variants of the peroneal tendons may cause tendon disorders. Moreover, there is a lack of evidence on how to address chronic tendon pathology when a variant of the peroneal tendons is causing the patient's symptoms. We present a patient with an uncommon peroneal muscle presentation: a single muscular belly dividing into both the peroneus longus and brevis tendons. After extensive debridement of tendinopathic tissue, primary repair or tenodesis was not possible; therefore a unique solution for this problem was performed, reconstructing both peroneal tendons using a semitendinosus allograft.

Reversal of Peroneal Tenodesis With Allograft Reconstruction of the Peroneus Brevis and Longus: Case Report and Surgical Technique.

Chronic peroneal tendinopathy and tears represent a challenging clinical situation. Traditionally, tenodesis of the torn tendon to the remaining healthy tendon has been advocated if more than half of the tendon is compromised. Allograft reconstructions have been reserved for patients with functional muscles and both peroneal tendons extensively compromised. We report a unique case of a peroneal tenodesis takedown and reconstruction of both peroneal tendons using semitendinosus allograft. A description of the surgical technique and tips are provided. Peroneal tendon function is crucial to maintain a balanced hindfoot. To the best of our knowledge, reconstruction of both peroneal tendons after a tenodesis has not been previously reported. Allograft reconstruction of the peroneal tendons arises as a feasible alternative in patients with residual pain and weakness after a failed tenodesis surgery LEVELS OF EVIDENCE: Therapeutic Level IV, case study.