Factors influencing treatment recommendations for base of 5th metatarsal fractures in orthopaedic residency programs.

BACKGROUND: Management of proximal 5th metatarsal fractures remains a controversial topic in orthopaedic surgery. Both operative and non-operative approaches have been described in the clinical setting. This confusion has led to non-standardized treatment recommendations for proximal 5th metatarsal fractures. This study was designed to analyze concordance rate of treatment recommendations between orthopaedic trainees and orthopaedic foot and ankle experts. METHODS: An online survey containing 14 cases of proximal 5th metatarsal fractures were distributed to 92 orthopaedic residents in two ACGME-accredited programs. Relevant weight-bearing radiographs, patient's age and gender were provided, and two questions regarding treatment recommendations were surveyed. Resident's recommended treatment was then matched against ultimate treatment by orthopaedic foot and ankle experts. ANOVA and T-test are used for associations between the rate of concordant treatment with PGY and trainee foot and ankle experience. Fleiss' kappa was used to assess the inter-observer agreement. RESULTS: Seventy-two residents returned the survey. The overall concordance rate was 43.98% with no correlation between agreement rate and PGY-years. No difference in agreement rate was observed between residents who had completed their foot and ankle rotation versus those who had not. There was a slight inter-observer agreement in recommending treatment among all residents (κ=0.117, 95% CI: 0.071-0.184). CONCLUSIONS: Our data demonstrated no significant concordance between resident level in training regarding proximal 5th metatarsal fracture treatment decisions, nor between residents and subspecialty-trained foot and ankle surgeons. Increased rotations with foot and ankle fellowship-trained surgeons throughout residency may be desirable to improve the quality of residency training. LEVEL OF EVIDENCE: III.

Minimally Invasive Cheilectomy for Hallux Rigidus.

Hallux metatarsophalangeal joint cheilectomy is a joint-sparing technique that involves resection of the dorsal metatarsal head osteophytes; this may be achieved through minimally invasive and arthroscopic techniques. General indications for minimally invasive surgery (MIS) cheilectomy are mild-to-moderate hallux rigidus (Grades I-II) with symptomatic dorsal osteophytes causing dorsal impingement and/or shoe wear irritation in those who have failed extensive nonoperative management. The literature confirms equivalent outcomes to open cheilectomy; however, it is somewhat inconsistent regarding superiority. The theoretic benefits of MIS cheilectomy include better cosmesis, reduced wound complications, less soft tissue disruption, and faster recovery.

The Effect of Tibiotalar Joint Line Level Alterations on Tibiotalar Range of Motion Following Total Ankle Arthroplasty.

BACKGROUND: The effect of tibiotalar joint line level (TTJL) on patient outcomes following total ankle arthroplasty (TAA) remains unclear. It was previously reported that patients with end-stage ankle arthritis have an elevated TTJL compared with nonarthritic ankles, and the TTJL post-TAA remains elevated compared with nonarthritic ankles. The objectives of this study were to (1) propose a reliable radiographic method to measure the TTJL absolute value and (2) determine the effect of TTJL alterations on tibiotalar range of motion (ROM) following TAA. METHODS: A retrospective review was performed on patients who underwent TAA between January 2018 and April 2021 with a minimum of 1-year postoperative follow-up and complete perioperative ROM radiographs. Radiographic TTJL and ROM measurements were performed by 2 observers. The proposed TTJL measuring technique computes 4 measurements: high, low, center of the talus (center), and center of the axis (axis). Reliability of measurements and correlation between TTJL measurements and ROM were assessed. RESULTS: A total of 33 patients were included. Postoperatively, 22 patients had a lowered TTJL compared to 11 patients with an elevated TTJL (2.2 ± 1.3 mm lowered vs 1.9 ± 1.2 mm elevated; P < .0001). Of the 4 TTJL measurements, 3 (low, center, axis) demonstrated a significant positive correlation between lowering the TTJL and improved tibiotalar dorsiflexion and 2 (low, axis) for total ROM (all P < .05). Plantarflexion was not significantly affected by TTJL alterations. Compared to patients with an elevated TTJL, patients with a lowered TTJL had improved tibiotalar dorsiflexion (8.8 vs 2.5 degrees; P = .0015) and total ROM (31.0 vs 22.9 degrees; P = .0191), respectively. The interrater reliability was nearly perfect (intraclass correlation r = 0.96-0.99). CONCLUSION: In this small series, we found that lowering the TTJL level may more closely reestablish the native TTJL and correlates with improved tibiotalar dorsiflexion and total ROM following TAA. LEVEL OF EVIDENCE: Level IV, case series.

A Novel Simulation Model and Training Program for Minimally Invasive Surgery of Hallux Valgus.

BACKGROUND: Minimally invasive surgery (MIS) for hallux valgus (HV) has gained popularity. However, adopting this technique faces the challenges of a pronounced learning curve. This study aimed to address these challenges by developing and validating an innovative simulation model and training program, targeting enhanced proficiency in HV MIS. METHODS: A training program and a high-fidelity simulation model for HV MIS were designed based on experts' recommendations. Four foot and ankle surgeons without experience in MIS formed the novice group and took the program that encompassed six-session instructional lessons, hands-on practice on simulated models, and immediate feedback. The program concluded with a cadaveric surgery. Four foot and ankle experienced MIS surgeons formed the expert group and underwent the same procedure with one simulated model. Participants underwent blind assessment, including Objective Structured Assessment of Technical Skills (OSATS), surgical time, and radiograph usage. RESULTS: Expert evaluation of the simulation model indicated high satisfaction with anatomical representation, handling properties, and utility as a training tool. The expert group consistently outperformed novices at the initial assessment across all outcomes, demonstrating OSATS scores of 24 points (range, 23 to 25) versus 15.5 (range, 12 to 17), median surgical time of 22.75 minutes (range, 12 to 27) versus 48.75 minutes (range, 38 to 60), and median radiograph usage of 70 (range, 53 to 102) versus 232.5 (range, 112 to 280). DISCUSSION: Novices exhibited a significant improvement in OSATS scores from the fifth session onward (P = 0.01), reaching the desired performance of 20 points. Performance at the final training with the simulated model did not differ from cadaveric surgery outcomes for all parameters. CONCLUSION: This study validated a simulation model and training program, allowing nonexperienced HV MIS foot and ankle surgeons to enhance their surgical proficiency and effectively complete a substantial portion of the learning curve at the fifth session, and this performance was successfully transferred to a cadaver model. LEVEL OF EVIDENCE: III.

Tibiotalocalcaneal arthrodesis with bulk femoral head allograft for salvage of large defects in the ankle.

BACKGROUND: Tibiotalocalcaneal arthrodesis in patients with large segmental bony defects presents a substantial challenge to successful reconstruction. These defects typically occur following failed total ankle replacement, avascular necrosis of the talus, trauma, osteomyelitis, Charcot, or failed reconstructive surgery. This study examined the outcomes of tibiotalocalcaneal (TTC) arthrodesis using bulk femoral head allograft to fill this defect. METHODS: Thirty-two patients underwent TTC arthrodesis with bulk femoral head allograft. Patients who demonstrated radiographic union were contacted for SF-12 clinical scoring and repeat radiographs. Patients with asymptomatic nonunions were also contacted for SF-12 scoring alone. Preoperative, intraoperative, and postoperative factors were analyzed to determine positive predictors for successful fusion. RESULTS: Sixteen patients healed their fusion (50% fusion rate). Diabetes mellitus was found to be the only predictive factor of outcome; all 9 patients with diabetes developed a nonunion. In this series, 19% of the patients went on to require a below-knee amputation. CONCLUSIONS: Although the radiographic fusion rate was low, when the 7 patients who had an asymptomatic nonunion were combined with the radiographic union group, the overall rate of functional limb salvage rose to 71%. TTC arthrodesis using femoral head allograft should be considered a salvage procedure that is technically difficult and carries a high risk for complications. Patients with diabetes mellitus are at an especially high risk for nonunion. LEVEL OF EVIDENCE: Level IV, retrospective case series.

The Hallux Metatarsophalangeal Capsule: An Anatomic Study With Respect to Percutaneous Hallux Valgus Correction.

BACKGROUND: Minimally invasive surgery for the treatment of hallux valgus deformities has become increasingly popular. Knowledge of the location of the hallux metatarsophalangeal (MTP) proximal capsular origin on the metatarsal neck is essential for surgeons in planning and executing extracapsular corrective osteotomies. A cadaveric study was undertaken to further study this anatomic relationship. METHODS: Ten nonpaired fresh-frozen frozen cadaveric specimens were used for this study. Careful dissection was performed, and the capsular origin of the hallux MTP joint was measured from the central portion of the metatarsal head in the medial, lateral, dorsal, plantarmedial, and plantarlateral dimensions. RESULTS: The ten specimens had a mean age of 77 years, with 5 female and 5 male. The mean distances from the central hallux metatarsal head to the MTP capsular origin were 15.2 mm dorsally, 8.4 mm medially, 9.6 mm laterally, 19.3 mm plantarmedially, and 21.0 mm plantarlaterally. CONCLUSION: The MTP capsular origin at the hallux metatarsal varies at different anatomic positions. Knowledge of this capsular anatomy is critical for orthopaedic surgeons when planning and performing minimally invasive distal metatarsal osteotomies for the correction of hallux valgus. TYPE OF STUDY: Cadaveric Study.

Effect of Achilles Tendon Lengthening and Gastrocnemius Recession on Radiographic Tibiotalar Motion Following Total Ankle Replacement.

BACKGROUND: Surgeons frequently add an Achilles tendon lengthening or gastrocnemius recession to increase dorsiflexion following total ankle replacement. Previous studies have looked at the effects of these procedures on total tibiopedal motion. However, tibiopedal motion includes motion of the midfoot and hindfoot as well as the ankle replacement. The current study examined the effects of Achilles tendon lengthening and gastrocnemius recession on radiographic tibiotalar motion at the level of the prosthesis only. METHODS: Fifty-four patients with an average of 25 months follow-up after total ankle replacement were divided into 3 groups: (1) patients who underwent Achilles tendon lengthening, (2) patients who had a gastrocnemius recession, (3) patients with no lengthening procedure. Tibiotalar range of motion was measured on lateral dorsiflexion-plantarflexion radiographs using reference lines on the surface of the implants. RESULTS: Both Achilles tendon lengthening and gastrocnemius recession significantly increased tibiotalar dorsiflexion when compared to the group without lengthening. However, the total tibiotalar range of motion among the 3 groups was the same. Interestingly, the Achilles tendon lengthening group lost 11.7 degrees of plantarflexion compared to the group without lengthening, which was significant. CONCLUSION: Both Achilles tendon lengthening and gastrocnemius recession increased radiographic tibiotalar dorsiflexion following arthroplasty. Achilles tendon lengthening had the unexpected effect of significantly decreasing plantarflexion. Gastrocnemius recession may be a better choice when faced with a tight ankle replacement because it increases dorsiflexion without a compensatory loss of plantarflexion. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Current management of tarsometatarsal injuries in the athlete.

The frequency of foot injuries is increasing in certain athletes, particularly injuries to the tarsometatarsal joint complex. A high index of suspicion for this injury is required to make the diagnosis because the clinical signs often are subtle. A comprehensive examination along with bilateral weight-bearing plain radiographs of the foot should be obtained in any suspected midfoot injury. Further imaging studies and stress radiographs may assist in the diagnosis and direct management. Nonsurgical treatment can be considered in a stable sprain with less than 2 mm of diastasis between the first and second metatarsal bases on a weight-bearing AP foot radiograph. Any tarsometatarsal injury with displacement of more than 2 mm or instability requires surgical treatment. Various techniques and approaches have been described, depending on the injury pattern, including primary arthrodesis and ligament reconstruction. Anatomic reduction is the most critical goal in the treatment of these injuries.

Assessment of Bony Subfibular Impingement in Flatfoot Patients Using Weight-Bearing CT Scans.

BACKGROUND:: Lateral hindfoot pain in patients with flatfoot deformity is frequently attributed to subfibular impingement. It remains unclear whether this is primarily due to bony or soft-tissue impingement. No studies have used weight-bearing CT scans to evaluate subfibular impingement. METHODS:: Patients with posterior tibial tendonitis were retrospectively searched and reviewed. Subjects had documented flatfoot deformity, posterior tibial tenderness, weight-bearing plain radiographs, and a weight-bearing CT scan. CT scans were evaluated for calcaneofibular impingement on the coronal view and talocalcaneal impingement on the sagittal view. The distance between these structures was measured, along with the sinus tarsi volume. In the second part of this study, 6 normal volunteers underwent weight-bearing CT scans on a platform that held both feet in 20 degrees of varus, followed by 20 degrees of valgus. The same measurements were performed. RESULTS:: Thirty-five percent of flatfoot patients with posterior tibial tendonitis had bony impingement between the fibula and calcaneus on the coronal view. Thirty-eight percent had bony impingement between the talus and calcaneus on the sagittal view. Subjects with bony impingement based on CT scan had significantly higher talonavicular abduction angles on plain radiographs than those without impingement. Sinus tarsi volume decreased by more than half when the subtalar joint moved from varus to valgus in normal controls. CONCLUSION:: Bony subfibular impingement in patients with flatfeet was less common than previously reported. Accurate diagnosis of bony impingement may be useful for surgical decision-making. LEVEL OF EVIDENCE:: Level III, retrospective comparative study.

Plantar fasciitis: evaluation and treatment.

Plantar fasciitis is the most common cause of plantar heel pain. Its characteristic features are pain and tenderness, predominately on the medial aspect of the calcaneus near the sole of the heel. Considering a complete differential diagnosis of plantar heel pain is important; a comprehensive history and physical examination guide accurate diagnosis. Many nonsurgical treatment modalities have been used in managing the disorder, including rest, massage, nonsteroidal anti-inflammatory drugs, night splints, heel cups/pads, custom and off-the-shelf orthoses, injections, casts, and physical therapy measures such as shock wave therapy. Most reported treatment outcomes rely on anecdotal experience or combinations of multiple modalities. Nevertheless, nonsurgical management of plantar fasciitis is successful in approximately 90% of patients. Surgical treatment is considered in only a small subset of patients with persistent, severe symptoms refractory to nonsurgical intervention for at least 6 to 12 months.

Total ankle replacement: the Agility LP prosthesis.

The original design for the Agility ankle was developed and patented in the late 1970s. DePuy Orthopaedics began manufacturing the implant as the Agility Ankle System. Currently in the United States, the Agility is the most widely used ankle prosthesis. With more than 20 years of experience, the Agility Ankle System has the longest follow-up of any fixed-bearing device. Since its introduction, the Agility Ankle System has gone through several design modifications. This article briefly reviews the history of the Agility Total Ankle System and illustrates each of the modifications made with the LP implant.

Measuring Visualized Tendon Length in Peroneal Tendoscopy.

BACKGROUND: Despite multiple studies outlining peroneal tendoscopy, no study exists to evaluate how effective tendoscopy is at visualizing the peroneal tendons without missing a lesion. We sought to measure the length of the peroneal tendons that could be visualized using tendoscopy. METHODS: Ten fresh cadaveric specimens were evaluated using standard peroneal tendoscopy techniques. Peroneus longus and brevis tendons were pierced percutaneously with Kirschner wires at the edge of what could be seen through the camera. The tendon sheaths were then dissected and the distances from anatomic landmarks were directly measured. During zone 3 peroneus longus tendoscopy, a more distal portal site was created for the final 5 specimens. RESULTS: The peroneus brevis could be visualized through the entirety of zone 1 and up to an average of 19.5 mm (95% confidence interval, 16.5-22.5) from its insertion onto the base of the fifth metatarsal in zone 2. Peroneus longus could be visualized through the entirety of zones 1 and 2 and up to an average of 9.7 mm from its insertion onto the base of the first metatarsal in zone 3. This distance was decreased significantly with a more distal portal. The muscle belly of peroneus brevis terminated an average of 1.8 mm (-3.7 to 7.3) above the tip of the lateral malleolus. CONCLUSIONS: Despite limitations, these results suggest that the vast majority of the length of the peroneal tendons can be seen during routine peroneal tendoscopy. A more distal skin portal site may improve visualization of zone 3 of peroneus longus. CLINICAL RELEVANCE: This study confirms the ability of peroneal tendoscopy to see the entire tendon length with appropriate portal placement.

Measuring Visualized Joint Surface in Hallux Metatarsophalangeal Arthroscopy.

BACKGROUND: Arthroscopy has been increasingly used to evaluate small joints in the foot and ankle. In the hallux metatarsophalangeal (MTP) joint, little data exist evaluating the efficacy of arthroscopy to visualize the articular surface. The goal of this cadaveric study was to determine how much articular surface of the MTP joint could be visualized during joint arthroscopy. METHODS: Ten fresh cadaveric foot specimens were evaluated using standard arthroscopy techniques. The edges of the visualized joint surface were marked with curettes and Kirschner wires; the joints were then surgically exposed and imaged. The visualized surface area was measured using ImageJ® software. RESULTS: On the distal 2-dimensional projection of the joint surface, an average 57.5% (range, 49.6%-65.3%) of the metatarsal head and 100% (range, 100%-100%) of the proximal phalanx base were visualized. From a lateral view of the metatarsal head, an average 72 degrees (range, 65-80 degrees) was visualized out of an average total articular arc of 199 degrees (range, 192-206 degrees), for an average 36.5% (range, 32.2%-40.8%) of the articular arc. CONCLUSION: Complete visualization of the proximal phalanx base was obtained. Incomplete metatarsal head visualization was obtained, but this is limited by technique limitations that may not reflect clinical practice. CLINICAL RELEVANCE: This information helps to validate the utility of arthrosocpy at the hallux metatarsophalangeal joint.

Using Arthroscopic Techniques for Achilles Pathology.

Endoscopically assisted procedures have been established to provide the surgeon with minimally invasive techniques to address common Achilles conditions. Modifications to some of these techniques as well as improvements in instrumentation have allowed these procedures to provide similar clinical results to the traditional open surgeries while reducing wound complications and accelerating patient's recoveries. The available literature on these techniques reports consistently good outcomes with few complications, making them appealing for surgeons to adopt.

Oligometastatic prostate cancer to the navicular bone: case report.

This case of oligometastatic prostate cancer to the foot highlights the importance of: 1) metastasis remaining high in the differential for unexplained malady, in the setting of a primary cancer, despite an atypical presentation, and 2) comparing sequential imaging studies to baseline images, especially when remote, because subtle findings can declare themselves over time.

Reproducibility of computed tomography to evaluate ankle and hindfoot fusions.

BACKGROUND: Although plain radiographs have been historically used to evaluate the status of arthrodesis in the foot and ankle, computed tomography (CT) has gained popularity for evaluation of fusion status. The degree of fusion identified on CT scan has been correlated with functional outcome, with an arthrodesis area of 25-50% necessary for clinical success. In the clinical setting, orthopaedic surgeons often evaluate CT scans independently. The purpose of this study was to evaluate the interrater reliability of CT scans to assess the status of hindfoot or ankle fusions among orthopaedic foot and ankle surgeons. METHODS: Forty-one CT scans were identified retrospectively from the tertiary referral practices of 4 fellowship-trained orthopaedic foot and ankle surgeons. Inclusion criteria were patients with ankle, subtalar, or tibiotalocalcaneal fusions. Fusions with bulk allograft were excluded. All CT scans were completed at the investigating institution. The primary author (RAC) reviewed all CT scans to ensure the adequacy and completeness of the films. Images were blinded of any patient identifiers. All 4 surgeons individually reviewed the blinded scans and determined whether the arthrodesis site was greater than or less than 50% fused. Interrater reliability was completed via kappa analysis. RESULTS: Based on kappa analysis, there was high interrater reliability in the assessment of subtalar arthrodesis. This was not statistically significant for the evaluation of ankle arthrodesis. CONCLUSION: The CT scan has become instrumental in determining the adequacy of arthrodesis in the foot and ankle. The present study demonstrates the reliability of orthopaedic surgeons to ascertain the status of subtalar arthrodesis via CT scan. LEVEL OF EVIDENCE: Level IV, case series.

Particulated juvenile articular cartilage allograft transplantation for osteochondral lesions of the talus.

Osteochondral lesions of the talus can present a challenge to the orthopedic surgeon. Because of its avascular nature, articular cartilage has a poor capacity for self-repair and regeneration. A wide variety of strategies have been developed to restore the structure and function of injured cartilage. Surgical strategies range from repair of cartilage through the formation of fibrocartilage to a variety of restorative procedures, including tissue-engineering-based strategies. A novel treatment option involves the implantation of particulated articular cartilage obtained from a juvenile allograft donor, the DeNovo NT graft. This article reviews the DeNovo NT graft, its usage, and surgical technique.

Freiberg's disease.

Freiberg's disease is a relatively uncommon disorder of the metatarsal head. Although trauma and circulatory disturbances likely contribute major roles in its development, it is widely accepted that Freiberg's etiology is multifactorial. Conservative treatment, focused on offloading and relieving stress, is uniformly accepted as the appropriate initial management. Surgical management can broadly be categorized as procedures which attempt to correct the pathophysiology and halt its progression, and procedures which address the sequelae of later stage disease. Newer strategies, including osteochondral transplantation, attempt to restore the damage metatarsal cartilage with a viable osteochondral plug.