Contemporary Review: An Overview of the Utility of Patient-Reported Outcome Measurement Information System (PROMIS) in Foot and Ankle Surgery.

Patient-Reported Outcome Measurement Information System (PROMIS) has favorable psychometric and administrative properties in orthopaedic clinical research. It facilitates clinically meaningful data collection while minimizing administration time and survey fatigue and improving compliance. PROMIS is a critical component of patient-centered care and shared decision making, as it provides enhanced communication and engagement between patients and providers. As a validated instrument, it may also aid in measuring value-based health care quality. The goal of the current work is to provide an overview of PROMIS metrics used in orthopaedic foot and ankle, including advantages and disadvantages compared to legacy scales and PROMIS's applicability in specific foot and ankle conditions based on psychometric properties. We provide a review of the literature regarding the utilization of PROMIS as an outcome measure for specific foot and ankle procedures and conditions.

Fractures of the posterior malleolus: a systematic review and analysis of patient-reported outcome scale selection.

PURPOSE: Despite the extensive use of PROs in ankle fracture research, no study has quantified which PROs are most commonly used for assessing outcomes of patients who sustain fractures of the posterior malleolus. The purpose of this study was therefore to quantify which PROs are most commonly used for outcome research after posterior malleolus fractures. METHODS: A systematic search was performed using the preferred reporting items for systematic reviews and meta-analyses guidelines. Articles were identified through Pubmed, EMBASE, Web of Science, and cochrane central register of controlled trials through May of 2021. Included articles were analyzed for the primary outcome of the most commonly reported PRO. RESULTS: The American orthopedic foot and ankle ankle-hindfoot score (AOFAS) was the most commonly used PRO for assessment of posterior malleolus fracture outcomes, used in 37 of 72 studies (51.4%). The second and third most common were the olerud-molander ankle score (OMAS) (22 studies, 30.6%) and the visual analogue score (VAS) (21 studies, 29.2%). Eleven different PROs were used only once. Quality of evidence was graded as low given the percentage of studies that were observational or case series (68 of 72 studies, 94.4%). CONCLUSION: Investigators have used many different PROs to assess outcomes for posterior malleolus fractures, the most common of which are the AOFAS, OMAS, and VAS. Future investigators should attempt to unify outcome reporting for these injuries.

Isolated fibular stress fractures: Radiographic parameters.

BACKGROUND: Fibular stress fractures are uncommon injuries with an incompletely understood pathogenesis and predisposing characteristics. This study investigated the demographic and radiographic risk factors for fibular stress fractures. METHODS: A retrospective chart review from 2010 to 2018 revealed thirteen patients with isolated fibular stress fractures. Demographics, history of fracture, fracture location, bone quality, and heel alignment were collected. RESULTS: The cohort consisted of six men and seven women with a mean age of 41.8 years. The average BMI was 28.5kg/m2. Three patients used tobacco. 69.2% of fractures were in the distal third, 23.1% proximal third, and 7.7% middle third. No patients had evidence of osteopenia. Distal fibula stress fractures were more common in women (66.7%) and associated with hindfoot valgus. CONCLUSION: Distal third fibula stress fractures were most common and associated with hindfoot valgus. This could be due to a greater amount of axial force through fibula in this alignment. LEVEL OF EVIDENCE: Level IV, Retrospective Case Series.

Functional Outcomes After Fracture-Dislocation of the Ankle.

Background. Fracture dislocation of the ankle represents a substantial injury to the bony and soft tissue structures of the ankle. There has been only limited reporting of functional outcome of ankle fracture-dislocations. This study aimed to compare functional outcome after open reduction internal fixation in ankle fractures with and without dislocation. Methods. A retrospective chart review of surgically treated ankle fractures over a 3- year period was performed. Demographic data, type of fracture, operative time and complications were recorded. Of 118 patients eligible for analysis, 33 (28%) sustained a fracture-dislocation. Mean patient age was 46.6 years; 62 patients, who had follow-up of at least 12 months, were analyzed for functional outcome assessed by the Foot and Ankle Outcome Score (FAOS). The median follow-up time was 37 months. Demographic variables and FAOS were compared between ankle fractures with and without dislocation. Results. The average age of patients sustaining fracture-dislocation was greater (53 vs 44 years, P = .017); a greater percentage were female (72.7% vs 51.8%, P = .039) and diabetic (24.2% vs 7.1%, P = .010). Wound complications were similar between both groups. FAOS was generally poorer in the fracture-dislocation group, although only the pain subscale demonstrated statistical significance (76 vs 92, P = .012). Conclusion. Ankle fracture-dislocation occurred more frequently in patients who were older, female, and diabetic. At a median of just > 3-year follow-up, functional outcomes in fracture-dislocations were generally poorer; the pain subscale of FAOS was worse in a statistically significant fashion. Levels of Evidence: Therapeutic, Level III.

Fibular Plate Fixation and Correlated Short-term Complications.

Background. The most common method of surgical stabilization of fibular fractures is plate osteosynthesis. Despite its ubiquity, there is a dearth of large series reporting implant-related outcomes and complications. The purpose of this study was to report on short-term complications and hardware removal after plate fixation of distal fibula fractures. Methods. A retrospective chart analysis and review of radiographic images was performed of 461 ankle fractures between 2011 and 2017. In 404 cases, a fibular fracture was treated surgically; 94.1% underwent tubular and 5.9% locking plate fixation. The primary outcome was radiographic union, with a mean follow-up of 11.6 months. Minor, intermediate, and major complications were recorded as well as the rate of hardware removal. Results. The union-rate with plate fixation was 99.5% (402/404). The overall complication rate was 19.3% (n = 78/404). Of these complications, 79.5% (62/78) were considered minor. These complications included erythema, heterotopic ossification, neurapraxia, delayed union, and deep-vein thrombosis; 20.5% (16/78) of the complications were considered intermediate (9/78, 11.5%) or major (7/78, 9.0%). Intermediate and major complications included deep infection, nonunion/malunion, and osteomyelitis. Subsequent surgery was needed in 7 cases (1.7%, 7/404). In another 93 patients, hardware-related symptoms were identified: 23 (5.7%) underwent syndesmosis screw removal and 54 (13.4%) hardware removal. No correlation to the fixation technique was identified. Conclusion. This study shows a relatively low rate of major complications and a high union rate of 99.5% for fibular plate osteosynthesis in a large cohort. Any other treatment, including other fixation techniques, will need to show an equivalent or better complication and reoperation profile.Level of Evidence: Level III: Retrospective, comparative study.

Timing of Open Reduction and Internal Fixation of Ankle Fractures.

Background. Unstable ankle fractures are treated with open reduction internal fixation (ORIF) to prevent posttraumatic arthritis. Typically, ORIF is performed as an ambulatory surgery several days to a few weeks after injury. It is unclear what effect this delay may have on functional outcome. This study aimed to assess the effect of timing of ankle ORIF on wound complications and functional outcome. Methods. A retrospective review of 121 patients who underwent ankle ORIF was performed. A total of 58 patients had a follow-up of at least 24 months. Time between injury and surgery greater than 14 days was defined as "delayed." Demographic variables, injury characteristics, length of surgery, and postoperative stay were documented. Comparison of demographic variables, wound complications, and functional outcome determined by Foot and Ankle Outcome Score (FAOS) was performed. Results. 118 patients were included. The duration between injury and surgery was 6 days in the "early" group and 19 days in the "delayed" group. There were no significant differences in demographic variables, injury characteristics, and length of surgery between the groups. Wound complications in the early and delayed groups were 5% and 11.8%, although this difference was not statistically significant. Among 58 patients who had a follow-up of at least 24 months, the median follow-up time was 38 (range, 24-76) months. Each subscale of FAOS demonstrated no significant difference. Conclusion. Ankle ORIF more than 14 days after injury did not significantly increase the rate of wound complication, nor did it impair ultimate functional outcome in this group. Levels of Evidence: Level III.

Radiographic Results of Unicortical Medial Malleolar Fracture Fixation.

BACKGROUND:: Medial malleolar fractures commonly occur as part of rotational ankle fractures, which often require surgery. Different fixation techniques exist, including unicortical or bicortical lag-screw fixation. Bicortical screws that engage the lateral distal tibia have been noted to be biomechanically superior to unicortical ones with a lower failure rate. The authors of this study have used unicortical screws routinely. This study was initiated to investigate the clinical results of a large series of patients with unicortical medial malleolar fixation. METHODS:: Patients who underwent unicortical medial malleolar fracture fixation between 2011 and 2017 were reviewed. In total, 461 ankle fractures were identified with a mean follow-up of 11.4 months (range, 3-57), of which 211 had a medial malleolar fracture. Eight patients were excluded as they did not follow up with the treating surgeons after surgery, leaving 203 patients for evaluation. The primary outcome was radiographic union. Any loss of reduction, complication, or subsequent surgery was recorded. Malunion was defined as greater than 2 mm displacement. RESULTS:: There were 2 asymptomatic nonunions (1.0%), 1 delayed union that healed using an external bone growth stimulator (0.5%), and 2 malunions of the medial malleolus (1.0%) with 1 asymptomatic. The other patient developed posttraumatic osteoarthritis but has not yet required further surgery. None of these 5 patients required revision medial malleolar surgery. Ultimately, the union rate using unicortical medial malleolar fixation was 99.0% (201/203). CONCLUSION:: Unicortical fixation of medial malleolar fractures resulted in consistently good healing. Even though biomechanical studies have shown that bicortical screws provide stronger fixation, our clinical results indicate that the need for this stronger fixation may be questionable. LEVEL OF EVIDENCE:: Level IV, retrospective case series.

Professional Soccer Players' Return to Play and Performance After Operative Repair of Achilles Tendon Rupture.

BACKGROUND: The majority of Achilles tendon ruptures are sports related; however, no investigation has examined the impact of surgical repair for complete ruptures on professional soccer players. PURPOSE: To examine the return to play, playing time, and performance of professional soccer players following Achilles tendon repair. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Union of European Football Associations (UEFA) and Major League Soccer (MLS) athletes who sustained a primary complete Achilles tendon rupture and were treated surgically between 1988 and 2014 were identified via public injury reports. Demographic information and performance-related statistics for the identified athletes were recorded for the season before surgery and 2 seasons after surgery and were compared with information for matched controls. Statistical analyses were used to assess differences in recorded metrics. RESULTS: A total of 24 athletes with Achilles ruptures met inclusion criteria, 17 (70.8%) of whom were able to return to play. On average, players had 8.3 years of professional-level experience prior to sustaining an Achilles rupture. Among athletes who returned to play, no differences were found in the number of games played or started, minutes played, or goals scored 1 year postoperatively compared with the year prior to injury. However, 2 years postoperatively, these athletes played 28.3% (P = .028) fewer minutes compared with their preoperative season, despite starting and playing in an equivalent number of games. Matched controls had baseline playing time and performance statistics similar to those of players. However, controls played and started in significantly more games and played more minutes at 1 and 2 years compared with players (P < .05). No differences were found in goals scored at any time point. CONCLUSION: This is the first investigation examining the effect of an Achilles repair on the career of professional soccer players. This is a difficult injury that most commonly occurs in veteran players and prevents 29.2% of players from returning to play despite surgical management. Additionally, athletes able to return to play were found to play fewer minutes 2 years postoperatively compared with their baseline as well as playing less at 1 and 2 years postoperatively compared with uninjured matched controls. The reduction in playing time following an Achilles repair has significant implications for professional players and teams.

Time to Diagnosis and Treatment of Surgical Site Infections in Foot and Ankle Surgery.

BACKGROUND: The time at which patients typically present with surgical site infections (SSI) following foot and ankle surgery has not been characterized. The primary aim of this study was to quantify the time to definitive treatment of SSIs. METHODS: We performed a retrospective review of 1933 foot and ankle procedures in 1632 patients from 2011 through 2015. Demographic and surgical data were collected. Time to presentation in cases diagnosed with postoperative wound complications or SSIs was analyzed. Wound complications were defined as any case with concerning wound appearance that subsequently resolved with antibiotic therapy alone. SSIs were defined as cases requiring operative irrigation and debridement (I&D) for successful definitive management. RESULTS: A total of 1569 procedures met inclusion criteria, with 17 SSIs (1.1%) and 63 wound complications (4.0%). Time between surgery and definitive treatment in the SSI group was significantly greater than in the wound complication group (28.2 ± 9.1 vs 13.4 ± 4.7 days, P < .00001). Eleven (64.7%) cases in the SSI group failed a trial of antibiotics prior to I&D, and 6 (35.3%) cases did not receive antibiotics prior to I&D. Antibiotic treatment prior to I&D did not significantly decrease the yield of intraoperative wound cultures (70% vs 100%, P = .51). CONCLUSION: In our cohort of patients, the time to diagnosis and treatment of SSIs was longer than that of wound complications. SSIs requiring operative intervention did not present until an average of 4 weeks after surgery. These data are of some benefit in trying to define and understand SSI. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Seasonal Variation of Achilles Tendon Injury.

BACKGROUND: Achilles tendon rupture (ATR) is a common injury with increasing incidence. Several risk factors have been identified; however, little is known about seasonal variations in injury prevalence. Previous reports have generated mixed results, with no clear consensus in the literature. The purpose of this investigation was to retrospectively review ATRs seen at a major academic orthopaedic surgery department in New York City to determine whether a statistically significant seasonal pattern of ATRs exists. METHODS: A retrospective chart review was conducted, identifying patients with an acute ATR. Patients were excluded if they had a chronic rupture, laceration, débridement for tendinitis, Haglund deformity, or other nonacute indications for surgery. Date and mechanism of injury were determined from the clinical record. RESULTS: The highest rate of injury was seen in spring (P = 0.015) and the lowest in fall (P < 0.001), both of which were statistically significant. Overall, no statistically significant difference was noted in summer or winter, although more injuries were seen in summer. When only sports-related injuries are considered, a similar trend is seen, with most injuries occurring in spring (n = 48, P = 0.076) and fewest in fall (n = 25, P = 0.012); however, only the lower number in fall reaches statistical significance. No statistically significant difference was noted between seasons when only non-sports-related injuries were considered. CONCLUSION: A statistically significant increase was noted in the incidence of ATRs in spring and a statistically significant decrease in fall. The need for recognition of risk factors and preventive education is increasingly important in the orthopaedic surgery community and for primary care physicians, athletic trainers, coaches, and athletes. LEVEL OF EVIDENCE: Prognostic level IV.

Professional Athletes' Return to Play and Performance After Operative Repair of an Achilles Tendon Rupture.

BACKGROUND: Most Achilles tendon ruptures are sports related. However, few studies have examined and compared the effect of surgical repair for complete ruptures on return to play (RTP), play time, and performance across multiple sports. PURPOSE: To examine RTP and performance among professional athletes after Achilles tendon repair and compare pre- versus postoperative functional outcomes of professional athletes from different major leagues in the United States. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: National Basketball Association (NBA), National Football League (NFL), Major League Baseball (MLB), and National Hockey League (NHL) athletes who sustained a primary complete Achilles tendon rupture treated surgically between 1989 and 2013 were identified via public injury reports and press releases. Demographic information and performance-related statistics were recorded for 2 seasons before and after surgery and compared with matched controls. Statistical analyses were used to assess differences in recorded metrics. RESULTS: Of 86 athletes screened, 62 met inclusion criteria including 25 NBA, 32 NFL, and 5 MLB players. Nineteen (30.6%) professional athletes with an isolated Achilles tendon rupture treated surgically were unable to return to play. Among athletes who successfully returned to play, game participation averaged 75.4% ( P < .001) and 81.9% ( P = .002) of the total games played the season before injury at 1 and 2 years postoperatively, respectively. Play time was significantly decreased and athletes performed significantly worse compared with preoperative levels at 1 and 2 years after injury ( P < .001). When players were compared with matched controls, an Achilles tendon rupture resulted in fewer games played ( P < .001), decreased play time ( P = .025), and worse performance statistics ( P < .001) at 1 year but not 2 years postoperatively ( P > .05). When individual sports were compared, NBA players were most significantly affected, experiencing significant decreases in games played, play time, and performance. CONCLUSION: An Achilles tendon rupture is a devastating injury that prevents RTP for 30.6% of professional players. Athletes who do return play in fewer games, have less play time, and perform at a lower level than their preinjury status. However, these functional deficits are seen only at 1 year after surgery compared with matched controls, such that players who return to play can expect to perform at a level commensurate with uninjured controls 2 years postoperatively.

Increasing age in Achilles rupture patients over time.

BACKGROUND: The changing demographics of Achilles tendon rupture (ATR) patients have not fully been investigated. However, there has been a general suspicion that this injury is occurring in an increasingly older population, in terms of mean age. The aim of this study was to objectively show an increase in age in Achilles tendon rupture patients over time. METHODS: Published literature on Achilles tendon ruptures was searched for descriptive statistics on the demographics of patients in the studies, specifically mean and median age of Achilles tendon rupture patients, gender ratio, percentage of athletics-related injuries, percentage of smokers, and BMI. Linear regression analyses were performed to determine the trend of patient demographics over time. A Welch one-way ANOVA was carried out to identify any possible differences in data obtained from different types of studies. RESULTS: The patient demographics from 142 studies were recorded, with all ATR injuries occurring between the years 1953 and 2014. There was no significant difference in the mean age data reported by varying study types, i.e. randomized controlled trial, cohort study, case series, etc. (P=0.182). There was a statistically significant rise in mean age of ATR patients over time (P<0.0005). There was also a statistically significant drop in percentage of male ATR patients (P=0.02). There is no significant trend for percentage of athletics-related injuries, smoking or BMI. CONCLUSION: Since 1953 to present day, the mean age at which ATR occurs has been increasing by at least 0.721 years every five years. In the same time period, the percentage of female study patients with ATR injuries has also been increasing by at least 0.6% every five years. LEVEL OF EVIDENCE: Level III; Retrospective cohort study.

Timing of Antibiotic Prophylaxis for Preventing Surgical Site Infections in Foot and Ankle Surgery.

BACKGROUND: Surgical site infections (SSIs) are one of the most troublesome complications after foot and ankle surgery. Previous literature has emphasized the significance of appropriate timing of antibiotic prophylaxis. However, the optimal timing of antibiotic prophylaxis for SSI prevention is still inconclusive. Our study aimed to investigate the optimal timing of antibiotic administration and to elucidate the risk factors for SSIs in foot and ankle surgery. METHODS: A retrospective review of 1933 foot and ankle procedures in 1632 patients from January 1, 2011, through August 31, 2015, was performed. Demographic data; type, amount, and timing of antibiotic administration; incision; and closure time were recorded. Subsequent wound infection and incision and drainage procedure (I&D) within 30 days and 90 days were documented. Outcomes and demographic variables were compared between procedures in which antibiotics were administered less than 15 minutes and between 15 to 60 minutes prior to incision. A total of 1569 procedures met inclusion criteria. RESULTS: There were 17 cases (1.1%) of subsequent wound infection, of which 6 required a subsequent I&D within 30 days. There were 63 additional cases (4%) of wound complications, which did not meet SSI criteria. When comparing SSI and non-SSI groups, the only significant independent predictors were longer surgeries and nonambulatory surgeries (both P < .05). Stepwise multivariate logistic regression analysis demonstrated that 91.8% of the risk of an SSI could be predicted by ASA score and length of surgery alone. CONCLUSION: In foot and ankle surgeries, the timing of intravenous antibiotic prophylaxis did not appear to play a significant role in the risk of SSI. Host factors and duration of surgery appear to have played a much larger role in SSI than the timing of antibiotic prophylaxis. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

A new method for achieving compression in hindfoot arthrodesis.

BACKGROUND: When performing hindfoot arthodeses, one goal of fixation is often to achieve compression across the joint. Traditional lag screws are applied eccentrically, providing compression more on the edge of the fusion. A new technique, using a post in one bone and a lag screw through the post to the other bone, may offer better compression across more of the joint. METHODS: There are three parts to this study comparing a post-and-screw construct to traditional lag screws. Synthetic bone models, representative of the talonavicular joint, were created and assessed for biomechanical measures of compression. Next, the post-and-screw construct was tested in cadavers, under conditions representing early weight bearing after arthrodesis surgery. Finally, 18 patients who had a talonavicular fusion with a post-and-screw construct with one surgeon were compared to the previous 18 patients fixed with traditional screws. RESULTS: In the synthetic bone model, the post-and-screw construct brought the centre of compression closer to the centre of the joint, suggesting compression was less eccentric. Neither traditional screws nor the post-and-screw construct were sufficiently strong to resist early weight bearing forces in cadaver specimens. In the clinical comparison, four patients had a painful nonunion when fixed with traditional screws, compared to none in the post-and-screw construct. CONCLUSIONS: A post-and-screw construct spreads the forces of compression more uniformly across an arthrodesis, even when placed eccentrically. Although not all the biomechanical measures were superior, the post-and-screw construct achieved higher levels of successful fusion in patients. This technology may offer improved outcomes in some clinical scenarios and deserves further study. LEVEL OF EVIDENCE: Level 3.

Nitric oxide-associated chondrocyte apoptosis in trauma patients after high-energy lower extremity intra-articular fractures.

BACKGROUND: The primary goal of this study was to identify nitric oxide (NO)-induced apoptosis in traumatized chondrocytes in intra-articular lower extremity fractures and the secondary goal was to identify the timeline of NO-induced apoptosis after injury. MATERIALS AND METHODS: This is a prospective collection of samples of human cartilage harvested at the time of surgery to measure apoptotic cell death and the presence of NO by immunohistochemistry. Three patients met the criteria for control subjects and eight patients sustained high-energy intra-articular fractures and were included in the study. Subjects who sustained intra-articular acetabular, tibial, calcaneal and talus fracture had articular cartilage harvested at the time of surgical intervention. All 8 patients underwent open reduction and internal fixation of the displaced intra-articular fractures. The main outcome measures were rate of apoptosis, degree of NO-induced apoptosis in chondrocytes, and the timeline of NO-induced apoptosis after high-energy trauma. RESULTS: The percentage of apoptotic chondrocytes was higher in impacted samples than in normal cartilage (56 vs 4 %), confirming the presence of apoptosis after intra-articular fracture. The percentage of cells with NO was greater in apoptotic cells than in normal cells (59 vs 20 %), implicating NO-induction of apoptosis. The correlation between chondrocyte apoptosis and increasing time from injury was found to be -0.615, indicating a decreasing rate of apoptosis post injury. CONCLUSIONS: The data showed the involvement of NO-induced apoptosis of chondrocytes after high-energy trauma, which decreased with time from injury.

How long should patients be kept non-weight bearing after ankle fracture fixation? A survey of OTA and AOFAS members.

BACKGROUND: Ankle fractures are common injuries treated routinely by orthopaedic surgeons. A variety of different post-operative protocols have been described with differing periods of non-weight bearing after surgery. The aim of this study was to identify how patient injury characteristics and medical comorbidities contribute to the period of non-weight bearing chosen by orthopaedic surgeons after open reduction and internal fixation of rotational ankle fractures. METHODS: A cross sectional expert opinion survey was administered to members of the AOFAS as well as OTA to determine how long they would instruct patients to be non-weight bearing after open reduction and internal fixation of ankle fractures. Three different injury characteristics were described: supination external rotation type 4 equivalents, bimalleolar, and trimalleolar patterns. These patterns were combined with three different medical statuses: young and healthy, older and healthy, and older with significant medical comorbidity. Respondents selected how long they would keep the patient non-weight bearing after surgery for each of the potential scenarios. Finally, they were directly asked which factors they felt affected their decision about length of time to keep patients non-weight bearing. RESULTS: Seven hundred and two surgeons (31%) responded to the survey. The average time of non-weight bearing selected varied from 4.9 (± 3.1) weeks for in young, healthy patients with SER4 equivalent injuries to 7.6 (± 6.0) weeks for older patients with medical comorbidities with trimalleolar fractures. Responses had a high degree of heterogeneity, but both injury pattern and medical status were significant predictors of non-weight bearing period (p<0.01), with medical status the stronger determinant. CONCLUSIONS: There is significant variation among orthopaedic surgeons when selecting period of non-weight bearing after fixation of ankle fractures, with both injury pattern and medical comorbidity playing a role in decision of time to keep patient non-weight bearing. Further research further evaluating the relationship between these factors and safe periods of non-weight bearing could help identify patients that may benefit from earlier mobilization, and improve surgeon's comfort with early mobilization. LEVEL OF EVIDENCE: Therapeutic Level V.

The failed first metatarsophalangeal joint implant arthroplasty.

Chronic pain in a first metatarsophalangeal implant arthroplasty can be early or late, and may be due to infection or implant failure. Although excisional arthroplasty can be considered, the most predictable result will come from arthrodesis. Conversion of a failed implant arthroplasty to fusion will usually require structural bone graft, with slower healing times than primary fusion.

Mobility of the first ray in various foot disorders.

BACKGROUND: Instability of the first ray has been proposed by Morton and others to be a major cause of several foot disorders, including hallux valgus, transfer metatarsalgia, lesser metatarsal stress fractures, and second metatarsophalangeal diseases. However, there are few studies to support these theories. In this study, we have used a simple device to measure first ray elevation and translation in a consecutive series of foot and ankle patients. We propose that mobility of the first ray will be increased in patients with hallux valgus, metatarsalgia, hallux rigidus, lesser metatarsal stress fractures, posterior tibial tendinitis, and interdigital neuromas. METHODS: Measurements of first ray translation and elevation were made in 345 feet in 315 patients. One or more pathologic diagnoses were recorded for each foot, and data was analyzed by a statistician. RESULTS: First ray mobility was increased in females compared to males. Patients with hallux valgus and metatarsalgia had greater mobility than other patients. Those feet with low arches showed greater mobility than those with high arches. Patients with hallux rigidus showed decreased mobility. We failed to find any differences for patients with stress fractures, posterior tibial tendinitis, or neuromas, but some of these groups may have had insufficient power. CONCLUSION: First ray translation and elevation are two different measures of medial column instability. Although they are distinct measures, they closely paralleled each other in this series. An association was found between increased first metatarsal elevation and several foot disorders. Although such an association does not prove causation, and it is likely other factors may play a role in many patients, this data does link instability of the first ray to some diseases. The decreased mobility seen in patients with hallux rigidus may offer new insights into the etiology of that disorder.

Achilles lengthening procedures.

Contracture of the gastrocnemius-soleus complex with equinus deformity is a common hindfoot condition. In children, it is frequently associated with neuromuscular conditions such as cerebral palsy. In the adult population, it is linked to numerous pathologies such as adult-acquired flatfoot, diabetic neuropathic ulcers, and plantar fasciitis. With the medial column reduced, failure to achieve 10 degrees of passive ankle dorsiflexion with the knee flexed and extended suggests a contracture. This article reviews the anatomical and evolutionary basis for human foot structure, implications of tight gastrocnemius, and specific disease states. Operative releases for lengthening, including proximal gastrocnemius recession, tendo-Achilles lengthening, and endoscopic recession, are detailed.