Novel Extramedullary Fixation Device for Hammertoe Correction: A Retrospective Review of 100 patients.

Classically, one of the more common treatment options for rigid hammertoe correction consists of end-to-end arthrodesis stabilized by temporary Kirschner wire (K-wire) fixation maintained until osseous consolidation or complication necessitating premature removal. However, single K-wire fixation allows for axial rotation which results in loss of compression at the arthrodesis site. To counteract this, intramedullary implants were designed to provide fusion site stability in all planes negating extra-skeletal extension of the wire. Nevertheless, manual pressfit implants arguably offer less reliable positioning of the fusion site in a true end to end orientation due to variation in intramedullary stem placement compared to direct visualization with dorsal plating. Larger diameter implants create an osseous void at the bony interface reducing the potential of true bony union. Hammertoe implant failure poses a unique and challenging salvage scenario which can ultimately end in amputation. Extramedullary fixation is uniquely designed to merge both benefits of K-wires and intramedullary implants while eliminating inadequacies of each. A total of 100 patients who underwent 150 rigid hammertoe corrections with an extramedullary implant were retrospectively reviewed. The mean postoperative follow-up was 12.6 months (range 12-18 months). Overall, 94 of 100 patients (94%) achieved radiographic union, defined by 2 or more bridged cortices at the arthrodesis site without signs of hardware breakage or signs of lucency across one or more fusion sites at a mean 8.8 weeks (range 7-10 weeks). This study demonstrated excellent results in regards to postoperative arthrodesis when utilizing an extramedullary implant for hammertoe deformity correction. This device minimizes osseous deficit by extramedullary application, all while augmenting intramedullary K-wire fixation.

Use of Small Joint Arthroscopy for Diagnosis and Treatment of a First Metatarsal Head Osteochondral Defect: A Case Report.

CASE: A case of a painful first metatarsophalangeal joint in a 28-year-old woman is reported. Clinical examination and imaging were suspicious for osteochondral lesion of the first metatarsal head. A 1.9-mm arthroscope was used for diagnosis and treatment of an osteochondral defect with microfracture and dehydrated, micronized allogenic cartilage application with an excellent postoperative outcome. CONCLUSION: From the 3-month through 1-year follow-up, the patient continued a pain-free return to normal function. This case suggests that arthroscopy is as a viable approach to resurfacing osteochondral lesions of the big toe joint.

Manifestation of Nonuremic Calciphylaxis in the Extremities: Case Report and Review.

Nonuremic calciphylaxis is a rare condition presenting with peripheral ischemic ulcerations. Calciphylaxis is the deposition of calcium and phosphate into arteriolar walls caused by exceeding their solubility range in the blood. It is most commonly seen in patients with end-stage renal disease; however, nonuremic calciphylaxis occurs in patients with normal or mildly impaired renal function. Risk factors for nonuremic calciphylaxis include Coumadin therapy, obesity, and diabetes mellitus. Histopathologic examination of deep skin biopsy containing subcutaneous adipose tissue reveals medial calcification of dermal and subcutaneous arterioles. This diagnosis must be managed locally with wound care and systemically by control of blood calcium solubility. Avoidance of infection is critical to survival. Here we report a case of calciphylaxis in a patient with normal renal function and serum levels of calcium and phosphorus who presented with gangrene of the extremities. Increased awareness of this debilitating disease will lead to earlier diagnosis, proper treatment and improved patient outcomes.

Relative Strengths of Intramedullary K-Wire Techniques for Digital Deformities.

Hammertoe deformity correction surgery is one of the most common procedures performed by foot and ankle surgeons. Recent foot and ankle medical literature presents conflicting opinions regarding the optimal intramedullary fixation device and techniques for use in digital deformity correction. There are a number of varying fixation constructs of intramedullary Kirschner wire fixation reported for proximal interphalangeal joint arthrodesis; however, there are no reports of relative loading strength of the fixations. In this study, 90 sawbone models were divided equally into 3 groups of different intramedullary Kirschner wire fixation techniques: Group A- single straight, Group B- single bent, Group C- double bent. Each fixation construct underwent controlled axial loading and failure points were observed. Results showed no significant difference in load failure from all 3 groups with mean maximum force of Group A = 20N, Group B = 19.1N, and Group C =17.5N. We conclude that all Kirschner wire fixation options for digital deformity correction, will provide similar resistance to sagittal plane axial loads.

Intermediate-Term Outcomes of a Third-Generation, 2-Component Total Ankle Prosthesis.

BACKGROUND: Short-term outcomes for the INBONE I and INBONE II tibial stems have been favorable. The INBONE-II talus has been shown to have lower reoperation and failure rates compared to its predecessor at short term follow-up. The purpose of the present study was to assess mid-term outcomes for the third generation, two component total ankle prosthesis at 5 to 9 years follow-up, evaluating both the tibial and talar components. METHODS: All patients who underwent primary total ankle arthroplasty (TAA) with INBONE-II between July 2010 and July 2014 at a single institution and who were at least 5 years postoperative were included. A total of 15 ankles with a mean follow-up of 85 months (range, 61-113 months) met the criteria. Radiographs were assessed using coronal and sagittal alignment parameters preoperatively, at 6 weeks postoperatively, and at the most recent follow-up. Medical records were reviewed and revisions, reoperations, and complications were classified according to the criteria established by Vander Griend et al and Glazebrook et al, respectively. RESULTS: The survivorship of the prosthesis at a mean of 85 months was 93.7%. The coronal and sagittal tibiotalar alignments 6 weeks after surgery were 2.1 degrees (P = .081) and 36% (P = .15), respectively. Maintenance of this alignment was observed during the latest follow-up (P = .684 and P = .837, respectively). One ankle (6.7%) required early component revision, while 4 (26.7%) required a non-implant-related revision. Six complications (2 high grade, 1 intermediate, and 3 low) in 5 ankles (33.3%) were recorded according to the Glazebrook classification system. CONCLUSION: The present study is the first to report midterm follow-up after TAA with this third-generation, 2-component prothesis. High survivorship, maintenance of correction, and a low incidence of major complications were observed in this small case series. The most common complication overall was lateral gutter impingement, which accounted for the majority of the nonrevisional reoperations. LEVEL OF EVIDENCE: Level IV, case series.

Risk Factors for Early Failure of Fourth Generation Total Ankle Arthroplasty Prostheses.

A number of 2-component, fourth generation total ankle arthroplasty (TAA) prostheses have been introduced to the market in the past few years, as the popularity and indications for TAA have continued to expand. The purpose of the present study was to identify independent risk factors for the early failure of fourth generation TAA prostheses. A total of 97 ankles underwent TAA with a fourth generation prostheses (INFINITY, CADENCE) between August 2015 and June 2018 at a single institution and were at least 6 months postoperative (mean 18.3 months, range 6-43). The primary outcome assessed was the need for revision surgery, defined as removal of 1 or both metal components for any reason, excluding infection. Baseline patient demographics, characteristics, radiographic alignment parameters, and distal tibia cortical bone thickness (CBT) were assessed. Revisions, reoperations, and complications were classified according to the criteria established by Vander Griend et al and Glazebrook et al, respectively. Univariate and multivariate analyses were performed. Three ankles (3.1%) underwent revision surgery for aseptic loosening at a mean of 24.3 (range, 16-31) months; all had a CBT <4 mm. Independent predictors for reoperation were CBT <4 mm, presence of diabetes, and ipsilateral hindfoot fusion (p = .04). No associations were identified for purported risk factors (age, body mass index, and coronal deformity). The present study is the first to suggest a potential relationship between reduced CBT of the distal tibia, and TAA failure. Additional studies are warranted to better understand the role of bone density in TAA survivorship.

Intrinsic Fixation of the Tibial Sesamoid in First Metatarsophalangeal Joint Arthrodesis: A Cadaveric Study.

Nonunion rate of first metatarsophalangeal joint (MTP) joint arthrodesis is reportedly less than 6%, regardless of fixation type. Robust modern plating constructs aim to decrease incidence of nonunion while also allowing early postoperative weight-bearing. Quicker transition to weight-bearing postoperatively increases patient adherence, decreases adjacent joint stiffness, and reduces risk of deep vein thrombosis in the postoperative period. The purpose of this study was to investigate the effect tibial sesamoid fixation has on first MTP joint arthrodesis.

Acute Deltoid Ligament Repair in Ankle Fractures: Five-year Follow-up.

Direct repair of deep deltoid ruptures after traumatic ankle fracture is not commonly performed. Previous studies overlook the contributions of the medial deltoid to overall ankle stability and long-term patient satisfaction. Historically, deep deltoid injuries have been addressed indirectly through syndesmotic ligament repair. This technique fails to restore, however, the anatomic function of the primary medial stabilizing structure. The oversight of direct deltoid repair may be one contributing factor to the less than optimal outcomes after ankle fractures with syndesmotic injuries. This article reports a positive response with direct deep deltoid repair, at average 5-year follow-up, with 93% positive return to normal function.

Syndesmotic Ligament Allograft Reconstruction for Treatment of Chronic Diastasis.

Chronic diastasis after a syndesmotic injury can lead to ankle joint instability and loss of joint congruence. Failure to restore the fibula into the proper anatomic position within the incisura increases the focal stress on the talus and can accelerate degenerative joint destruction. In the case of failed syndesmotic repair, fixation options are limited. If promptly diagnosed, the syndesmosis may be amenable to open debridement and subsequent fixation with 2 interosseous screws. If latent diastasis is found, however, syndesmotic fusion by bone block arthrodesis is recommended. We present a syndesmotic allograft repair technique for surgical reconstruction of chronic unstable syndesmotic ruptures.

Cryopreserved Amniotic Membrane and Autogenous Adipose Tissue as an Interpositional Spacer After Resection of a Cubonavicular Coalition: A Case Report and Review of the Literature.

Coalitions of the hindfoot are a relatively rare but challenging condition encountered by foot and ankle surgeons. Those that manifest between the cuboid and navicular (cubonavicular coalitions) are seen even more infrequently and are estimated to comprise ∼1% of all tarsal coalitions. Treatment for cubonavicular coalitions parallels protocols for more common hindfoot coalitions. Typically, resection versus hindfoot arthrodesis procedures are used. The present study describes the case of a 34-year-old male with a painful cubonavicular coalition and early secondary signs of arthrosis. Despite the recommended guidelines of hindfoot arthrodesis, he elected for surgical resection. Autogenous adipose tissue and cryopreserved amniotic membrane were used for interposition at the resection site. This case demonstrates that surgical resection with interpositional grafting can be successful even in advanced disease states.

Does implantation of verruca plantaris into the abductor hallucis muscle belly in conjunction with CO2 laser ablation prevent recurrence?

Often times, conservative treatment is unsuccessful in long-term resolution of recalcitrant verrucae plantaris lesions. In addition to being aesthetically displeasing, severe cases that are left untreated can be debilitating, often leading to chronic pain, gait abnormalities, and further cutaneous spread. Inoculation through implantation of verrucae plantaris into a muscle was previously postulated to provoke an immune response against the human papilloma virus, resulting in auto-immunization. The purpose of this study was to determine the rate of recurrence following two methods of treatment: A) Surgical removal and subsequent implantation of verruca plantaris into the contralateral abductor hallucis muscle belly and B) Surgical excision of verrucae plantaris. A retrospective chart review of 43 consecutive patients was performed. Group A was comprised of 25 patients who underwent surgical removal of verrucae plantaris followed by implantation of a biopsied specimen into the contralateral abductor hallucis muscle belly. Group B was comprised of 18 patients who underwent only surgical removal of the verrucae. The presence or absence of verrucous lesions was recorded at a post-operative follow-up at an average of 27.5 months. Correlations between recurrence of disease and age, sex, and medical comorbidities were evaluated. Our results suggest that implantation of verruca plantaris into the abductor hallucis muscle belly yields no significant difference in clinical recurrence rates when compared to surgical removal.

Osteochondral Defect of the Calcaneocuboid Joint: A Case Study.

Osteochondral lesions (OCLs) are injuries affecting the articular cartilage surface of a joint. OCLs are well reported in the literature to affect the knee, talus, tibia, navicular, and first metatarsal. This rare case of a bipolar osteochondral lesion of the cuboid and calcaneus presented as lateral heel pain after a traumatic injury. After an unsuccessful course of conservative therapy, the lesion was treated with curettage and application juvenile particulate cartilage allograft. Eight months postoperatively, the patient was ambulating in supportive shoe gear without pain. The mechanism of injury leading to calcaneocuboid joint osteochondral lesions is not clearly understood. It is also questionable whether anatomic variances are contributory. Regardless of causality, OCLs should be included in the differential diagnoses for patients presenting with calcaneocuboid joint or lateral hindfoot pain.