Predictive Factors of Postoperative Pain in Patients With Tibiotalocalcaneal Arthrodesis With an Intramedullary Nail: A Retrospective Review.

Tibiotalocalcaneal arthrodesis has been shown in literature to have good results in regards to low complication rates and deformity correction. While previous studies have investigated functional outcomes and complication rates, no large-scale studies have looked at pain outcomes. The present study performed a retrospective review of 154 extremities to analyze how a patient's comorbidities and characteristics influence pain outcomes following a tibiotalocalcaneal arthrodesis. The present study found an average change of pain from 7.1 to 3.0 in at least a 6 month follow up. We found that a diagnosis of chronic pain and tobacco use had statistically significant less pain improvement compared to patients without chronic pain or current tobacco use. We determined no statistically significant difference in pain outcomes for patients with or without Charcot deformity. Lastly, we found that with older patients there was more pain improvement observed. We physicians can educate current tobacco users of the improved pain outcomes with tobacco cessation prior to surgery. We recommend a multidisciplinary approach for pain in patients with a pre-operative diagnosis of chronic pain and to educate patients on realistic postoperative pain outcomes.

Tension Side Fixation for Lapidus Arthrodesis: A Retrospective Analysis.

Moderate to severe hallux valgus deformity often requires a Lapidus procedure (first-tarsometatarsal arthrodesis). Traditional methods include a dorsal approach with dorsal or medial fixation. However, studies demonstrate plantar/tension-side fixation, provides superior load to failure and fixation strength. This could improve outcomes, address comorbidities, and accelerate postoperative protocols; however, a paucity exists for patient outcomes in the literature regarding tension-side-fixation. The purpose of this study is to report the outcomes for tension-side Lapidus fixation. A retrospective analysis was performed of 81 patients who underwent tension-side-fixation Lapidus. Data collection consisted of: time to weight-bear, time to return to regular shoegear, hardware removal rate, revision rate, recurrence rate, relative metatarsal shortening, and nonunion rates. Mean patient age was 44 years old (range: 16-82). There were 65 females, and 16 males. The average time to weightbearing was 10.4 days. Time to return to regular shoegear was a mean of 6 weeks (ranging 2-10 weeks). Hardware removal rate was 1.2%. The recurrence rate was 8.6% (7 of 81 patients) and 5 of those 7 patients experienced recurrence before frontal-plane-correction was adopted by the surgeon. The revision rate was 0% and despite 8.6% recurrence, no patients were dissatisfied or requested a revisional procedure. The first-metatarsal shortening was a mean of 0.42 mm. The complications were as follows: 7% superficial dehiscence, 1.2% superficial wound infection, 0% deep infection, and 1.2% asymptomatic nonunion. This study suggests tension-side-fixation for Lapidus arthrodesis may allow for safe early return to weightbearing, early return to regular shoegear, low hardware removal rate, low revision rate, low metatarsal shortening, and low nonunion rate.

Optimizing Subtalar Arthrodesis: A Human Cadaveric Evaluation of a Novel Partially-Threaded Screw Combination in the Delta Configuration.

Background and Objectives: Despite the established role of subtalar joint arthrodesis (SJA) for treatment of subtalar osteoarthritis, achieving bone union remains challenging, with up to 46% non-union rates. Adequate compression and stable fixation are crucial for successful outcomes, with internal screw fixation being the gold standard for SJA. The delta configuration, featuring highly divergent screws, offers stability, however, it can result in hardware irritation in 20-30% of patients. Solutions to solve this complication include cannulated compression screw (CCS) countersinking or cannulated compression headless screw (CCHS) application. The aim of this biomechanical study was to investigate the stability of a delta configuration for SJA utilizing either a combination of a posterior CCHS and an anterior CCS or a standard two-CCS combination. Materials and Methods: Twelve paired human cadaveric lower legs were assigned pairwise to two groups for SJA using either two CCSs (Group 1) or one posterior CCHS and one anterior CCS (Group 2). All specimens were tested under progressively increasing cyclic loading to failure, with monitoring of the talocalcaneal movements via motion tracking. Results: Initial stiffness did not differ significantly between the groups, p = 0.949. Talocalcaneal movements in terms of varus-valgus deformation and internal-external rotation were significantly bigger in Group 1 versus Group 2, p ≤ 0.026. Number of cycles until reaching 5° varus-valgus deformation was significantly higher in Group 2 versus Group 1, p = 0.029. Conclusions: A delta-configuration SJA utilizing a posterior CCHS and an anterior CCS is biomechanically superior versus a standard configuration with two CCSs. Clinically, the use of a posterior CCHS could prevent protrusion of the hardware in the heel, while an anterior CCS could facilitate less surgical time and thus less complication rates.

Bilateral first metatarsophalangeal joint arthrodesis: An investigation of functional, surgical and radiological outcomes.

BACKGROUND: First metatarsophalangeal joint (MTPJ) arthrodesis is a commonly utilised procedure. In this study, the authors aim to explore functional outcomes of patients undergoing nonsynchronous bilateral first MTPJ arthrodesis under the care of a single surgeon using a compression screw/locking plate construct. METHODS: This is a prospectively collected, retrospectively analysed case series of fifty five patients who underwent bilateral nonsynchronous first MTPJ arthrodesis. Clinical and radiological outcomes were assessed preoperatively and at a minimum of two years postoperatively. Clinical outcomes were assessed using the Foot and Ankle Outcome Score (FAOS), the Self-Reported Foot and Ankle Score (SEFAS) and the Sports Questionnaire version 1 (SQ). Postoperative radiographs were used to assess evidence of union and compare both hallux valgus and intermetatarsal angles. Removal of hardware, revision surgery and correction of deformities were also recorded. RESULTS: Fifty five patients were included in the study. There was statistically significant improvements in all five facets of the FAOS (p value < 0.05). The mean postoperative SEFAS was 45.1. In total, patients participated in thirteen different sporting activities. This represented 92 patient specific activities preoperatively and 104 postoperatively. The most common activities were walking, cycling and swimming. Overall, 94.5% (N = 52) of the cohort were satisfied with their return to sport while 98.2% (N = 54) would recommend bilateral first MTPJ arthrodesis. Mean reductions in hallux valgus angles and intermetatarsal angles were noted at 18.87 and 4.69 degrees respectively. There was one non-union in the cohort which required revision surgery. One patient required removal of hardware. CONCLUSIONS: Bilateral first MTPJ arthrodesis is a safe and effective surgical option for patients with bilateral first MTPJ pathology. It has a high union rate, low complication rate and significantly improves clinical outcomes and allows patients reliably return to physical activities.

Outcomes following tibiotalocalcaneal arthrodesis using a solid posterior offset intramedullary nail in 44 patients with a minimum 30-month follow-up.

BACKGROUND: Tibiotalocalcaneal arthrodesis is frequently performed by foot and ankle surgeons in the management of complex ankle and hindfoot pathology. In this study, the authors describe the clinical and radiological outcomes of tibiotalocalcaneal arthrodesis using a solid posterior offset hindfoot arthrodesis nail. METHODS: Forty-four consecutive patients underwent tibiotalocalcaneal arthrodesis by a single surgeon operating in two centers. Clinical and radiological outcomes were assessed preoperatively and at 6-month, 12-month and final follow-up (mean 47 months). Clinical outcomes were assessed with VAS, AOFAS and MOXFQ scores. Serial radiographs were used to assess union at each follow-up visit. RESULTS: Forty-four patients attended 12-month and final follow-up (mean 47 months). A total of 44 (100%) ankle joints and 44 (100%) subtalar joints were completely united at 12-month follow-up. The VAS score improved significantly from a mean of 6.5 preoperatively to a mean of 0.98 at final follow-up (P = <0.0001). AOFAS score improved significantly from a mean of 36.4 preoperatively to a mean of 73 at final follow-up (P = <0.0001). MOXFQ score improved significantly from a mean of 44.5 preoperatively to a mean of 12.7 at final follow-up (P = <0.0001). The mean change in frontal plane alignment was 5.7 degrees (P = 0.005). A total of 6 patients (13.6%) had an adverse event during the course of the study. CONCLUSIONS: Tibiotalocalcaneal arthrodesis with a solid posterior offset hindfoot arthrodesis nail is a safe and effective surgical option for patients with severe ankle and hindfoot pathology. It has a high union rate, low complication rate and significantly improves clinical outcomes.

Polyvinyl alcohol hydrogel implant for the treatment of hallux rigidus is associated with a high complication rate and moderate failure rate at short-term follow-up: a systematic review.

PURPOSE: Moderate-to-severe hallux rigidus is a debilitating pathology that is optimally treated with surgical intervention. Arthrodesis produces reliable clinical outcomes but is limited by restriction in 1st metatarsophalangeal joint range of motion. The advent of polyvinyl alcohol hydrogel (PVA) implants have produced early promise based on initial trials, but more recent studies have called into question the efficacy of this procedure. The purpose of this systematic review was to evaluate the clinical and radiological outcomes following the use of PVA for hallux rigidus. METHODS: The MEDLINE, EMBASE and Cochrane library databases were systematically reviewed using the preferred reporting items for systematic reviews and meta-analyses guidelines. 18 studies were included. RESULTS: In total, 1349 patients (1367 feet) underwent PVA at a weighted mean follow-up of 24.1 ± 11.1 months. There were 168 patients (169 feet) included in the cheilectomy cohort and 322 patients (322 feet) included in the arthrodesis cohort. All 3 cohorts produced comparable improvements in subjective clinical outcomes. Postoperative imaging findings in the PVA cohort included joint space narrowing, peri-implant fluid, peri-implant edema and erosion of the proximal phalanx. The complication rate in the PVA cohort, cheilectomy cohort and arthrodesis cohort was 27.9%, 11.8% and 24.1%, respectively. The failure rates in the PVA cohort, cheilectomy cohort and arthrodesis cohort was 14.8%, 0.3% and 9.0%, respectively. CONCLUSION: This systematic review demonstrated that PVA produced a high complication rate (27.9%) together with concerning postoperative imaging findings at short-term follow-up. In addition, a moderate failure rate (14.8%) and secondary surgical procedure rate (9.5%) was noted for the PVA cohort. The findings of this review calls into question the efficacy and safety of PVA for the treatment of hallux rigidus. LEVEL OF EVIDENCE: IV.

Limb salvage reconstruction of the lower limb with complex ankle arthrodesis and magnetic internal lengthening nail.

PURPOSE: With advances in orthopedic implants, the use of intramedullary lengthening devices has gained increasing popularity as an alternative technique compared to lengthening with external fixators, with alleged comparable or better outcomes. The aim of this study is to report our single-center technique and outcomes of combined ankle arthrodesis and proximal tibial lengthening using external fixator with a motorized intramedullary nail, respectively. METHOD: Fourteen patients with post-traumatic advanced ankle arthritis underwent staged ankle arthrodesis with external fixator and proximal tibial lengthening using the PRECICE® ILN. Amount of shortening, length achieved, bone healing index, infection rate, ankle fusion rate, and ASAMI score were evaluated. RESULTS: The average age was 44 years old (range, 30-62). The mean follow up is 70 months (range, 43-121.4). The average amount of limb shortening for patients after ankle fusion was 36.7 mm (18-50) while lengthening was 35.9 mm (range, 18-50). Patients had the nail implanted for an average of 479 days (range, 248-730). Ankle fusions were healed in an average of 178.3 days. There were no surgical infections. All osteotomy-lengthening sites healed after an average 202 days (106-365). The mean bone healing index (BHI) was 56.0 days/cm (21.2-123.6) among the whole cohort. There were no cases of nonunion. ASAMI bone scores were excellent or good among all patients. CONCLUSION: Ankle arthrodesis with external fixation along with proximal tibial lengthening using motorized IMN yielded high rates of fusion and successful lengthening. This technique could be offered as a reasonable alternative to using external fixation for both purposes. LEVEL OF EVIDENCE: Level IV, Retrospective cohort study.

Has the Threshold for Epiphysiodesis Versus Lengthening Changed in the Era of Magnetically Controlled Nails?

INTRODUCTION: Limb length discrepancy (LLD) is common in both the pediatric and adult population. Length inequalities can be due to a multitude of etiologies including congenital, developmental, and acquired causes. There has been little consensus on the morbidity of LLD and, as a result, the threshold necessary for treatment of LLD to prevent morbidity. Advances in magnetically controlled lengthening devices achieve greater accuracy and patient satisfaction and create an opportunity to lower the threshold for limb lengthening. DISCUSSION: Asymptomatic LLD is relatively common in both pediatric and adult populations. Only ~10% of the population has equal leg length. LLD of <5 cm may lead to long-term morbidities such as scoliosis, lower back pain, gait abnormalities, stress on hip or knee joint, and lower extremity symptomatic versus asymptomatic osteoarthritis. The teaching in most orthopaedic textbooks is to adjust the shoe if symptomatic for discrepancies up to 2 cm; consider an orthotic, epiphysiodesis, or skeletal shortening for 2.5 to 5 cm; and possible limb reconstruction for >5 cm. The assumption is that there are no long-term consequences of mild LLD. However, data in recent literature show that small discrepancies may contribute to pathologic changes such as pain, gait abnormalities, and osteoarthritis. Major advances have been made in limb lengthening over the past 40 years. The increased accuracy and superior patient satisfaction of the magnetically controlled lengthening nail versus external fixation methods argue for including lengthening for LLD of <5 cm. CONCLUSION: If mild LLD can cause long-term pathology, it is important to counsel families on the full range of options for limb equalization no matter the size of the discrepancy. The evolution in technology and understanding of limb lengthening has provided additional safe surgical options. Therefore, the historic treatment protocol for addressing limb differences may need to include lengthening for smaller discrepancies even <2 cm.

A retrospective multicenter study on the use of locking compression plates for scapulohumeral arthrodesis in small equids.

OBJECTIVE: To report on technical aspects and outcomes after scapulohumeral arthrodesis (SHA) with a locking compression plate (LCP) in small equids. STUDY DESIGN: Retrospective multicenter case series. ANIMALS: Client-owned Shetland Ponies, Miniature Shetlands, and American Miniature Horses (n = 15). METHODS: Inclusion criteria were completed SHA with an LCP to treat scapulohumeral osteoarthritis/subluxation and availability of postoperative radiographs. Contributing surgeons completed a questionnaire to collect data. All radiographs were reviewed for this study. Follow-up information was obtained via re-admission to the hospital or telephone interview of the referring veterinarian or owner. Outcome was subjectively scored as excellent, good, moderate, or poor based on lameness and function. RESULTS: Sixteen SHAs were performed in 15 equids (body weight 65-145 kg) by nine different surgeons. A narrow 4.5/5.0 mm LCP (7-16 holes) was used in 14 of the 16 SHAs. Follow-up was collected 2.5 years after surgery (median; range: 9 weeks to 10 years). Major complications related to the SHAs were noted in 4 of the 13 horses alive long term, consisting of implant failure (n = 1), surgical site infection (n = 2), and scapular fracture (n = 1). The outcome was graded as excellent in 4, good in 5, and moderate in 4 horses. Two ponies were euthanized because scapulohumeral osteoarthritis and subluxation developed in the contralateral limb. CONCLUSION: Although major complications occurred in about one-third of ponies, SHA with LCP led to long-term survival with good function in most ponies. CLINICAL SIGNIFICANCE: SHA with an LCP offers a high chance for good long-term outcome in small equids although contralateral disease may affect outcome.

Arthrodesis of the digital joint using intraosseous wiring in patients with rheumatoid arthritis.

OBJECTIVE: Digital joints affected by rheumatoid arthritis often have severe deformity and/or dislocation, and arthrodesis in a functional position is required. METHODS: Arthrodesis was performed using intraosseous wiring (modified Lister's method) from January 2011 to December 2015, and we investigated the union rate, postoperative complications, and patient satisfaction with the operation at the final follow-up. The DASH score, grip power, and pinch power were also investigated before the operation and at the final follow-up. RESULTS: Arthrodesis was performed for 90 digital joints in 56 patients. Bone union was obtained in 85 of 89 joints (96%). Wire removal was needed due to subcutaneous protrusion in 20 joints and superficial infection in five joints. The mean preoperative DASH score of 50.5 improved to 45.2 at the final follow-up. The pulp pinch power of the index fingers through the little fingers changed significantly. In the questionnaire regarding the operated digit using a visual analogue scale (VAS, 0 [worst] to 100 [best]), the overall satisfaction was 70. CONCLUSION: With this approach, we achieved painless stability as well as deformity correction. A restored prehensile pattern and improvement in the activities of daily life can thus be expected after surgery.

A cadaveric comparison of two methods for isolated talonavicular arthrodesis: Two-screws versus plate with integrated compression screw.

BACKGROUND: This study compared stiffness between two constructs for talonavicular arthrodesis: a dorsomedial plating system and two partially threaded cannulated cancellous screws. We hypothesized that the plate would exhibit greater stiffness and resistance to deformation during cyclic loading. METHODS: The constructs were implanted in eight matched pairs of cadaveric feet and subjected to axial torsion, cantilever bending in two directions, and cyclic loading to failure. RESULTS: The two-screw constructs were significantly stiffer in plantar-dorsal bending (p = .025) and trended towards a higher number of cycles before failure than the plate group (p = .087). No significant differences were observed in internal torsion (p = .620), external torsion (p = .165), or medial-lateral bending (p = .686). CONCLUSIONS: This study provided the first biomechanical assessment of a plating system with an integrated compression screw, which was significantly less stiff than a two-screw construct when loaded from plantar to dorsal.

Retrograde nailing, trabecular metal implant and use of bone marrow aspirate concentrate after failed ankle joint replacement.

BACKGROUND: Ankle fusion after removal of alloplasty is known to be a procedure with a high potential for non-unions and poor function, especially tibio-talo-calcaneal fusion. We wanted to review our results after using a novel method for the procedure, combining retrograde nailing with a trabecular metal implant and bone marrow aspirate concentration applied in an ostoconductive pad in addition to autologous bone grafting. MATERIALS AND METHODS: Retrospective review of a patient series, with some prospectively registered data. 31 ankles in 30 patients were operated from January 2016 to February 2019. RESULTS: There were two non-unions (6.5%), and one delayed union, none of these were reoperated. The mean postoperative Manchester-Oxford Foot and Ankle Questionnaire score (MOxFQ) was 33.6 points. 9 patients scored an average MOxFQ at 72.9 immediately before surgery, while at follow-up this had decreased to 36.2, an improvement of 36.7 points (95% CI 18.3-54.9). There were 1 minor infection and 5 possible nerve injuries. One patient had the leg amputated 1 year after the surgery due to a non-related necrotizing fasciitis. CONCLUSION: We present reasonably good short to medium term patient satisfaction and fusion rates with this novel combination of techniques.

Adverse events involving hallux metatarsophalangeal joint implants: Analysis of the United States Food and Drug Administration data from 2010 to 2018.

BACKGROUND: The prevalence of osteoarthritis of the hallux metatarsophalangeal joint (MTPJ) is 1 in 40 people over the age of 50. Surgical treatment options for MTPJ arthritis include joint preservation, joint resurfacing, and arthrodesis. Hallux MTPJ implants have evolved over the past several decades, but are associated with various complications. The aim of this study was to examine the MAUDE database to determine reported adverse events for hallux MTPJ implants. MATERIALS AND METHODS: The US Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database was reviewed from 2010 to 2018 to review voluntary reported adverse event reports for approved implants within the United States. We recorded the type of adverse event and excluded duplicate reports and those extracted from already published literature. RESULTS: Among 64 reported hallux MTPJ implant adverse events, the most common modes of adverse events were component loosening (34%), infection (14.1%), component fracture (9.4%), inflammation (9.4%), and allergic reaction (7.8%). Regarding implant type, Cartiva SCI had the highest percentage of adverse events (23.4%), followed by Arthrosurface ToeMotion (20.3%), Ascension MGT (12.5%), Arthrosurface HemiCAP® (10.9%), Futura primus (9.4%), and Osteomed Reflexion (6.3%). There was an increase in reported adverse events after 2016. The MAUDE database does not report the total incidence of implant insertion. CONCLUSION: Our study of the MAUDE database demonstrated that component loosening and infection are the most common modes of adverse events for hallux MTPJ implants. Cartiva accounted for one-fourth of the implant-related adverse events during our study period, followed by ToeMotion, and Ascension MGT implants. Continued reporting of adverse events will improve our understanding on short and long-term complications of various hallux MTPJ implants. LEVEL OF EVIDENCE: Level IV; Case Series from Large Database Analysis; Treatment Study.

Screw Anterior Distal Femoral Hemiepiphysiodesis in Children With Cerebral Palsy and Knee Flexion Contractures: A Retrospective Case-control Study.

BACKGROUND: In children with cerebral palsy who demonstrate hamstring tightness, increasing attention is being paid to less invasive methods of correcting knee flexion contractures. Guided growth principles represent one such approach, and in tandem with a serial extension casting protocol, may provide a less invasive method of addressing these contractures. To date, no evidence is available on this combination of procedures. The purpose of this study was to investigate the effectiveness of a combined lengthening/guided growth procedure (hamstring lengthening, percutaneous anterior screw hemiepiphysiodesis, and serial extension casting) in addressing knee flexion contracture, and to compare this approach to hamstring lengthening and serial extension casting alone. METHODS: Measures from preoperative and postoperative gait analyses were reviewed retrospectively for 10 patients with cerebral palsy who underwent anterior screw hemiepiphysiodesis and hamstring lengthening followed by serial extension casting [anterior epiphysiodesis (AE) group]. These findings were compared with measures from 19 patients with cerebral palsy who underwent hamstring lengthening followed by serial extension casting [no anterior epiphysiodesis (NAE) group]. Postoperative changes in clinical, functional, and kinematic parameters were assessed. Radiographic parameters were also assessed for the AE group. RESULTS: In the AE group, improvements were measured in knee contracture, popliteal angle, peak stance phase knee extension, knee range of motion, and Gait Deviation Index. Similar results were observed in the NAE group. In the AE group, the lateral distal femoral angle increased into extension by 20.9 degrees at an average of 26-month follow-up. Both groups showed an increase in pelvic tilt postoperatively. There were no surgical complications associated with the screw anterior hemiepiphysiodesis. Four patients did have complaints of knee pain, but the pain was attributable to the implants in only one patient. DISCUSSION: The AE group demonstrated statistically greater postoperative improvement in popliteal angle, knee flexion contracture, and peak knee extension during stance than the NAE group. Both procedures led to improvements in clinical and functional measures, indicating the validity of this approach as a means of correcting flexion contracture that is less invasive and allows immediate weight bearing. LEVEL OF EVIDENCE: Level III-therapeutic study.

Low-profile locking-plate vs. the conventional AO system: early comparative results in wrist arthrodesis.

INTRODUCTION: Total wrist arthrodesis represents a reliable salvage procedure for severe painful conditions of the wrist. To date, wrist arthrodesis using a dorsal plate reaching from the distal radius to the third metacarpal is still recommended. A new implant (APTUS© 2.5 TriLock Wrist Fusion Plate, Medartis Suisse) that does not cross the third carpometacarpal joint (CMCJ-3) has been introduced recently. The purpose of this retrospective study was to compare both implants concerning early functional and clinical results. MATERIALS AND METHODS: A total of 20 patients underwent total wrist arthrodesis [10, using the new APTUS© implant (APT); 10 using the Depuy-Synthes© LCP plates (AO)]. The postoperative control interval was 18.2 and 37.2 months in APT and AO, respectively. Clinical assessment included functional parameters such as active range of motion (AROM) for pronation and supination, grip strength, and passive range of motion of the CMCJ-3. Additionally the DASH score and the Krimmer wrist score as well as pain levels at rest and under stress conditions were evaluated. RESULTS: All patients showed osseous healing without complications except one case of non-union in APT. There were no significant differences between both groups concerning grip strength, AROM of the wrist, pain levels, DASH- and Krimmer Score. APT showed a significantly increased passive range of motion of the CMCJ-3 compared to the unaffected contralateral side. CONCLUSIONS: The new implant shows similar functional results compared to the standard procedure. The main advantage of the new implant is the fact that no implant removal is necessary due to the unaffected CMCJ-3. Furthermore the mobility of the CMCJ slightly increased and showed positive impact on hand kinematics.

Mid-term results of hindfoot arthrodesis with a retrograde intra-medullary nail in 24 patients with diabetic Charcot neuroarthropathy.

Background and purpose - Hindfoot arthrodesis using retrograde intramedullary nailing assumes a critical role in limb salvage for patients with diabetic Charcot neuro-arthropathy (CN). However, this procedure is compelling and fraught with complications in diabetic patients. We report the mid-term clinical and radiological outcomes of retrograde intramedullary nailing for severe foot and ankle deformity in patients with diabetic CN.Patients and methods - Hindfoot arthrodesis was performed using a retrograde intramedullary nail in 24 patients (15 females) with diabetic Charcot foot. The mean age of the patients was 62 years (33-82); the mean follow-up was 45 months (24-70). The primary outcomes were rates of fusion, limb salvage, and complications.Results - The overall fusion rate was 23/24, and none of the patients needed amputation. The rate of superficial wound infection was 4/24, and no deep infection or osteomyelitis was observed postoperatively.Interpretation - For selected cases of diabetic CN with severe foot and ankle deformity, hindfoot arthrodesis using a retrograde intramedullary nail seems to be a good technique in achieving fusion, limb salvage, and avoidance of complications.

How many screws are necessary for subtalar fusion? A retrospective study.

BACKGROUND: Biomechanical studies have shown a higher compressive force and higher torsional stiffness for fixation with three screws compared to two screws. However, clinical data to compare these fixation techniques is still lacking. METHODS: A retrospective analysis of 113 patients was performed, who underwent isolated subtalar fusion between January 2006 and April 2018. RESULTS: Revision arthrodesis was required in 8% (n=6/36) for 3-screw-fixation and 38% (n=35/77) for 2-screw-fixation. For 3-screw-fixation, non-union, was observed in 14% (n=5/36) compared to 35% (n=27/77) in 2-screw fixation. Non-union (p=.025) and revision arthrodesis (p=.034) were significantly more frequent in patients with 2 screws. A body mass index ≥30kg/m2 (p=.04, OR=2.6,95%CI:1.1-6.3), prior ankle-fusion (p=.017,OR=4.4,95%CI:1.3-14.5) and diabetes mellitus (p=.04,OR=4.9,95%CI:1.1-17.8) were associated with a higher rate of revision arthrodesis. CONCLUSIONS: Our findings suggest that successful subtalar fusion is more reliably achieved with use of three screws. However, future prospective studies will be necessary to further specify this recommendation.

First tarsometatarsal fusion using saw preparation vs. standard preparation of the joint: A cadaver study.

BACKGROUND: First tarsometatarsal (TMT) joint fusion is effective for treatment of arthritis and some first ray deformities. To prepare the articular surfaces, cartilage should be carefully but completely denuded. Inadequate preparation may result in non-union, while excessive preparation may cause ray shortening and consequential transfer metatarsalgia. Preparation can be performed with an osteotome or a saw. The purpose of this study was to investigate whether utilization of an osteotome or saw would minimize shortening of the first ray in TMT arthrodesis. METHODS: Ten fresh-frozen cadaver specimens were randomly assigned to undergo joint preparation using either an osteotome (n=5) or saw (n=5). Sample size was determined by cadaver availability. Fusion was performed using a cross-screw construct through the dorsal aspect of the proximal phalanx and the medial cuneiform. Pre- and post-operative X-rays were taken with a radiopaque ruler in the field, and changes in length in the first metatarsal and first cuneiform were compared between osteotome and sawblade groups. RESULTS: The average change in metatarsal length was significantly smaller in the osteotome group (1.6mm) as compared to the saw group (4.4mm) (p=0.031). The average percent change in metatarsal length was also significantly smaller in the osteotome group (3.0%) compared to the saw group (8.4%) (p=0.025). There was no significant difference between the two groups with respect to change in cuneiform length. The osteotome group demonstrated a significantly smaller average measured change (3.0mm vs. 6.9mm, p=0.001) and percent change (4.1% vs. 9.3%, p<0.001) in total length (cuneiform plus metatarsal) in comparison to the saw group. CONCLUSIONS: In first TMT fusion, joint preparation with an osteotome may prevent over-shortening of the first ray in comparison to preparation with a saw.

Anatomical study of Lapidus arthrodesis using two different plantar plate systems.

BACKGROUND: First tarsometatarsal arthrodesis (modified Lapidus procedure) constitutes a sufficient treatment for moderate to severe hallux valgus deformity and first ray instability. The plantar plate arthrodesis was shown to provide superior mechanical stability and less postoperative complications than screw fixation or dorsal plating. Nevertheless, the in-brought hardware may cause irritation of the tibialis anterior or peroneus longus tendon requiring explantation of the material in some cases. The purpose of this study was to investigate the potential of tendon irritation after plantar first tarsometatarsal joint arthrodesis in a cadaver study. METHODS: Plantar plate arthrodesis was performed as in real surgery on twelve pairs of fresh frozen cadaveric feet. Two different plate systems were randomly allocated to each pair of feet. After plate fixation careful dissection of the feet followed to analyze potential tendon irritation and to determine a "safe zone" for plantar plate placement. RESULTS: A "safe zone" between the insertion sties of tibialis anterior and peroneus longus tendon was found and proven to be sufficiently exposed using a standard medio-plantar approach. Both plates were fixed in this zone without compromising central tendon parts. Peripheral tendon parts were irritated in 42% using Darco Plantar Lapidus Plating System® (Wright Medical, Memphis, TN) and in 8% using the Plantar Lapidus Plate® (Arthrex, Naples, FL). Bending of the anatomically preshaped plates is often necessary to ensure optimal fit on the bone surface. CONCLUSIONS: Modified Lapidus procedure with plantar plating of the first tarsometatarsal joint can be performed safely without compromising central tendon parts via standard medio-plantar approach. LEVEL OF CLINICAL EVIDENCE: 5, Cadaver Study.

Prognostic risk factors for complications associated with tibiotalocalcaneal arthrodesis with a nail.

BACKGROUND: Tibiotalocalcaneal (TTC) arthrodesis with a nail can be an effective salvage procedure for several foot and ankle pathologies, but has a relatively high complication rate. The purpose of this study is to investigate risk factors associated with complications after TTC arthrodesis with a nail. METHODS: Clinical and radiographic outcomes for 82 patients from 2012 to 2016 who underwent TTC arthrodesis with a nail were retrospectivelyevaluated to determine if patient or surgeon specific variables offered prognostic value in predicting negative outcomes. RESULTS: Diabetes, diabetic neuropathy, high (>2) American Society of Anesthesiologists (ASA) classification, and Charcot neuroarthropathy all were predictive of developing a nonunion in either the subtalar ortibiotalar joints (p<0.05). Diabetic neuropathy was predictive ofreoperation, and along with HbA1C >7.5 was also predictive of hardwarefailure. The odds ratio (OR) for diabetic neuropathy was 2.99 (p<0.05)for nonunion in the tibiotalar or subtalar joints, 3.46 (p<0.05) for reoperation,and 4.11 (p<0.05) for hardware failure. High ASAclassification had an odds ratio of 3.93 (p<0.05) for nonunion in the tibiotalar or subtalar joints as well. Diabetes had an odds ratio of 2.57 (p<0.05) for nonunion. CONCLUSIONS: Patients with diabetic neuropathy, Charcot neuroarthropathy, elevated HbA1C, and ASA classification >2 demonstrated a higher complication rate in patients undergoing TTC arthrodesis with a nail.