Addressing Transverse Plane Instability in the Modified Lapidus Arthrodesis: A Comparative Study of Screw Versus Suture and Button Fixation Device Technique.

The Lapidus arthrodesis is a powerful procedure for the correction of hallux valgus with metatarsus primus varus. Yet, first ray instability may persist despite correction of the primary deformity with 2 crossed screw fixation. A third screw is often utilized as the additional point of fixation for noteworthy residual transverse plane motion, but it is not without potential complications. The suture and button fixation device may be an appropriate alternative to the third screw construct. This retrospective cohort study identified clinical / radiographic outcomes and complication rates following a third point of fixation with either a screw or suture and button fixation device in patients undergoing a modified Lapidus arthrodesis. One surgeon performed all of the Lapidus procedure with a third screw while the other surgeon performed all with a suture and button fixation device. Of 136 consecutive patients who underwent a modified Lapidus arthrodesis, 83 (61%) patients required a third point of fixation for satisfactory stabilization of the first ray. Surgical technique was similar between the 2 surgeons; however, one utilized the suture and button fixation device method (n = 36), while the other used a third screw for fixation (n = 47). Many of the clinical outcomes, radiographic results, and the union rate were similar between the 2 methods. Nineteen (40%) complications occurred in the third screw group compared to 6 (17%) in the suture and button fixation device group. However, the third screw group demonstrated 100% maintenance of deformity correction at 1 year versus 95% in the suture and button fixation device group. Although fixation with a suture and button fixation device was associated with fewer complications, a larger study is necessary to determine if these variations are statistically significant.

Early Protected Weightbearing After Open Reduction Internal Fixation of Ankle Fractures With Trans-syndesmotic Screws.

Traditional postoperative care after open reduction internal fixation (ORIF) of unstable ankle fractures with syndesmotic instability includes non-weightbearing for 6 to 8 weeks. However, prolonged non-weightbearing may be detrimental. The goal of this case series was to assess the outcomes of early protected weightbearing after operative treatment of acute ankle fractures with syndesmotic instability requiring screw stabilization. Fifty-eight consecutive patients, treated from January 2006 to January 2013, met the inclusion criteria with a minimum follow up of 1 year. Electronic medical records and radiographs were reviewed for patient and surgical characteristics, postoperative complications, and maintenance of reduction. Patients initiated walking at an average of 10 days (range 1 to 15) postoperatively. Surgical treatment consisted of operative reduction with standard fixation devices and 1 or 2 trans-syndesmotic screws that purchased 4 cortices. All 58 patients maintained correction after surgery when allowed to weightbear early in the postoperative recovery. Five complications (8.6%) occurred in the 58 patients, which included 3 superficial infections (5.2%) and 2 cases (3.4%) of neuritis. The maintenance of reduction and low complication rate in this study support the option of early protected weightbearing after ankle fracture ORIF with trans-syndesmotic fixation.

Modified lapidus arthrodesis with crossed screw fixation: early weightbearing in 136 patients.

Modified Lapidus arthrodesis is a versatile and powerful procedure for correcting the hallux valgus deformity typically associated with significant metatarsus primus varus or increased first ray mobility. Traditionally, patients have remained non-weightbearing until the arthrodesis has consolidated. More recently, numerous studies have evaluated the outcomes of early postoperative weightbearing using a variety of fixation constructs. The present retrospective cohort study evaluated 136 consecutive patients who had undergone modified Lapidus arthrodesis for hallux valgus deformity with conventional, crossed, solid core, screw fixation, were enrolled in an early weightbearing protocol, and were followed for 12 months. All the patients were partial weightbearing in a protective boot a mean of 12.2 (SD ± 4.36) days after surgery, with full weightbearing at 34.4 (SD ± 11.89) days. Union was achieved in 133 patients (97.8%). Of the 3 (2.2%) patients with nonunion, 2 (1.5%) remained asymptomatic. The mean time to radiographic union was 65 (SD ± 37.24) days. Significant improvement was seen in the first intermetatarsal angle and hallux abductus angle after surgery (p < .0001). Deformity correction was not compromised by early weightbearing and was well maintained over time. These results support early weightbearing with traditional crossed screw fixation for modified Lapidus arthrodesis with outcomes and complication rates comparable to those previously published.

Fixation orientation in ankle fractures with syndesmosis injury.

Accurate reduction of the syndesmosis has been shown to be an important prognostic factor for functional outcome in ankle injuries that disrupt the syndesmosis. The purpose of the present case series was to assess the fixation orientation and the position of the fibula within the tibial incisura after open reduction and internal fixation of ankle fractures with syndesmosis injury. Computed tomography was used to assess the accuracy of the reduction. Twelve patients were included in the present case series. A ratio representing the relationship between the tibia and fibula and the orientation of the syndesmotic fixation was measured preoperatively and postoperatively and compared with the uninjured contralateral ankle, representing the patient's normal anatomy. The measurements were accomplished electronically to one tenth of 1 mm using Stentor Intelligent Informatics, I-site, version 3.3.1 (Phillips Electronics; Andover, MA). Posteriorly oriented syndesmotic fixation caused posterior translation of the fibula with respect to the tibia and anteriorly oriented syndesmotic fixation caused anterior translation.

Early protected weightbearing after open reduction internal fixation of ankle fractures.

The present retrospective study assessed the complications and loss of reduction in 126 patients aged 16 years or older who bore weight in a short leg cast within 15 days after surgical repair of acute unilateral closed ankle fractures from January 1997 to December 2003. Fracture reduction was assessed on immediate postoperative and weightbearing digital radiographs at least 6 weeks after surgery. The medical records were reviewed for postoperative complications. Complete radiographs were available for 81 patients. The mean follow-up period was 171 (range 42 to 1275) days. The mean patient age was 50 years. Patients began walking an average of 8 days after surgery. From the medical record review, no cases of malunion or nonunion occurred. A total of 14 complications developed in 12 (9.5%) of 126 patients, including a delay in wound healing in 6, nerve paresthesia in 5, and hardware migration in 1. The patients aged 60 years or older had a slightly greater overall complication rate (6 of 38, p = .18). Patients who walked on postoperative day 1 had slightly more wound problems (2 of 19, p = .36). Of the 81 ankle fracture radiographs, 80 (98.8%) showed no displacement in fracture reduction on the final follow-up examination. One patient had a 2-mm loss of fracture reduction and was allowed to walk on postoperative day 1 (p = .09). These results support early protected weightbearing after operative treatment of closed isolated lateral malleolar and bimalleolar ankle fractures without syndesmotic involvement in patients of all ages.

Bicortical fixation of medial malleolar fractures: a review of 23 cases at risk for complicated bone healing.

Several methods have been described for fixation of unstable medial malleolar fractures. Certain patient populations, including the elderly, those with osteoporosis and osteopenia, and patients with diabetes mellitus, are generally known to be susceptible to complications associated with ankle fracture healing. The goal of the present retrospective investigation was to review the outcomes of a series of patients who had undergone medial malleolar fracture repair using fully threaded bicortical interfragmental compression screw fixation. Patients were included in the present series if they had undergone bicortical fixation of an unstable ankle fracture with a medial malleolar fracture component, in addition to having at least 1 of the following comorbidities: age 55 years or older, osteoporosis or osteopenia, diabetes mellitus, peripheral arterial disease, end-stage renal disease, chronic kidney disease, previous kidney transplantation, peripheral neuropathy, or current tobacco use. A total of 23 ankle fractures in 22 consecutive patients met the inclusion criteria. The mean age of the patients was 69.52 (range 45 to 89) years; 17 were female (77.27%) and 5 were male (22.73%). Of the 23 medial malleolar fractures, 21 (91.3%) achieved complete, uncomplicated healing. The mean interval to union was 62.6 (range 42 to 156) days. A total of 4 complications (17.39%) were noted, including 1 nonunion (4.35%), 1 malunion (4.35%), and 2 cases of painful retained hardware (8.7%). From our experience with this series of patients, bicortical screw fixation for medial malleolus fractures appears to be an acceptable alternative for fixation that provides a stable construct for patients at greater risk of bone healing complications.

Inverted Z-scarf osteotomy for hallux valgus deformity correction: intermediate-term results in 55 patients.

The Z-scarf osteotomy is used for hallux valgus deformity correction by foot and ankle surgeons worldwide. Inverting the Z-scarf osteotomy configuration strengthens the construct in both sawbone and cadaver models, but clinical results of this configuration have not been reported in the literature. This retrospective study evaluates the subjective and intermediate-term postoperative radiographic results of 73 inverted Z-scarf osteotomy procedures for hallux valgus correction in 55 patients from January 1994 to December 2003. The modified University of Maryland 100-Point Painful Foot Center Scoring System demonstrated 52 patients (95%) with good to excellent results at a mean follow-up of 5 years (range 2-11 years). Radiograph measurements revealed the following: first-second intermetatarsal angle mean, 6.1° (range 2-14°), average reduction 4.6°; hallux abductus angle mean, 11.0° (range -8-30°), average reduction 10.1°; tibial sesamoid position mean, 2.3; first metatarsal protrusion distance mean, -2.1 mm. Two patients (2 of 73 feet) developed major complications: one progressed to clinically acceptable hallux varus; another sustained compromise of one fixation screw with minor displacement at the distal osteotomy that healed in satisfactory position after non-weight-bearing immobilization. There were no cases of osteonecrosis, delayed union, or nonunion. The inverted Z-scarf osteotomy, with advantages in both mechanical strength and technique of execution over the traditional configuration, demonstrates high patient satisfaction, restoration of normal radiographic parameters, and a low complication rate in this study.

Chevron arthrodesis of the interphalangeal joint for hammertoe correction.

Interphalangeal joint arthrodesis is a common procedure to correct fixed or semifixed lesser toe contracture. The authors present a simple modification to end-to-end interphalangeal joint arthrodesis that increases surface area and enhances construct stability. The technique is most commonly used for the proximal interphalangeal joint and may be combined with any number of fixation techniques.

Clear cell hidradenoma of the ankle.

Clear cell hidradenoma is a relatively common, benign eccrine neoplasm with rare presentations in the foot and ankle. Variable clinical and histopathologic characteristics of the tumor warrant careful consideration over primary and recurrent malignancy, particularly eccrine carcinoma. The first known case of primary benign clear cell hidradenoma of the ankle is presented with imaging studies, surgical management, and clinicopathologic correlation, distinguishing the neoplasm from its malignant counterparts.

Arthroscopic ankle arthrodesis: factors influencing union in 39 consecutive patients.

BACKGROUND: Arthroscopic ankle arthrodesis is an effective alternative to open techniques with established advantages in select patient populations. The purpose of this study was to evaluate patients who had arthroscopic ankle arthrodesis for end-stage arthritis with minimal to no deformity of the ankle and to report factors influencing union. METHODS: Thirty-nine consecutive patients had arthroscopic ankle arthrodesis between 1994 and 2003. Clinical records and radiographs were retrospectively reviewed to evaluate variables that could predispose patients to nonunion. Union outcomes were correlated with etiology of arthritis, ankle deformity, medical co-morbidities, and the use of demineralized bone matrix or platelet-rich plasma. Arthroscopic ankle arthrodesis was accomplished with a consistent technique using crossed transmalleolar cannulated screw fixation. RESULTS: Thirty-four of 39 patients (87.2%) achieved radiographic and clinical union. The average time to fusion was 47 (range 37 to 70) days. Poor bone quality and inherent positional ankle deformity were identified as risk factors for nonunion. Patients who smoked, had diabetes mellitus, peripheral neuropathy, or other medical co-morbidities attained ankle union in nearly all cases. In obese patients, there was an observed trend towards ankle nonunion (relative risk 5.81, p = 0.049, Fisher's Exact test). The addition of demineralized bone matrix or platelet-rich plasma did not improve the rate of ankle union. Aside from nonunion, 10 patients developed minor complications. CONCLUSION: Arthroscopic ankle arthrodesis achieves high union rates, facilitates short time to union, and permits rapid patient mobility. Careful patient selection is important for the procedure. Synthetic allograft or platelet-rich plasma did not enhance the fusion rate. Obese patients showed a trend towards nonunion in this series.

Deltoid ligament integrity in lateral malleolar fractures: a comparative analysis of arthroscopic and radiographic assessments.

Foot and ankle surgeons often rely on the medial clear space to evaluate competency of the deep deltoid ligament when evaluating ankle fractures. This investigation assesses the integrity of the deep deltoid ligament after lateral malleolar fracture by using direct arthroscopic visualization and medial clear-space separation on plain film radiographs. The objectives of this study were to test the reliability of medial clear-space separation and the Lauge-Hansen classification scheme in predicting deep deltoid rupture in displaced lateral malleolar fractures. The medial clear space was measured on injury radiographs of 40 patients with an isolated displaced lateral malleolar fracture who underwent open reduction and internal fixation. Injury radiographs were classified according to the Lauge-Hansen scheme. Direct arthroscopic visualization was used to evaluate the deep deltoid ligament under manual stress before fracture reduction. The mean preoperative medial clear space in patients with a deep deltoid rupture (n = 13) was 6.6 +/- 2.4 mm (range, 4 to 12 mm), and in patients without a deep deltoid rupture (n = 26), it was 4.0 +/- 1.0 mm (range, 2.5 to 6 mm) (P =.002, 2-sample t test). At an injury medial clear space > or =3 mm, the false positive rate for deltoid rupture was 88.5% (P =.54, Fisher's exact test). At > or =4 mm, the false positive rate was 53.6% (P =.007). All fractures were rotational injuries according to the Lauge-Hansen system. Three fractures were not classifiable; another 3 fractures showed deltoid ligament integrity opposite the expected finding. The results indicate that, in isolated displaced fractures of the lateral malleolus, radiographic widening of the medial clear space is not a reliable indicator for deep deltoid rupture. Some fractures considered stable by the Lauge-Hansen classification may require careful scrutiny to rule out deep deltoid injury.