Imaging of osteoarthritis from the ankle through the midfoot.

Ankle, hindfoot, and midfoot osteoarthritis (OA) is most commonly posttraumatic and tends to become symptomatic in younger patients. It often results from instability due to insufficiency of supportive soft tissue structures, such as ligaments and tendons. Diagnostic imaging can be helpful to detect and characterize the distribution of OA, and to assess the integrity of these supportive structures, which helps determine prognosis and guide treatment. However, the imaging findings associated with OA and instability may be subtle and unrecognized until the process is advanced, which may ultimately limit therapeutic options to salvage procedures. It is important to understand the abilities and limitations of various imaging modalities used to assess ankle, hindfoot, and midfoot OA, and to be familiar with the imaging findings of OA and instability patterns.

Anatomic Risk to the Neurovascular Structures With a Medially Based All-Inside Syndesmosis Suture Button Technique.

Recent evidence suggests that the use of suture button devices for ankle syndesmosis fixation is increasing. Multiple studies have shown some concern about damaging the greater saphenous neurovasculature with placement of the anchor point on the medial tibial cortex. We hypothesized that an all-inside button deployment technique would allow for a low risk to medial soft tissue structures. A total of 40 syndesmosis suture buttons were placed into 10 separate cadaveric lower limbs, using the newly developed technique. Four suture buttons were sequentially placed from distal to proximal in each limb within the zone of typical syndesmosis fixation, using fluoroscopic guidance. A medial incision was then performed to evaluate the relationship of the suture buttons to the medial soft tissue structures and the medial malleolus. Thirteen of 40 suture buttons (32.5%) were placed anterior, 7 (17.5%) posterior, and 20 (50%) with a portion of the button directly deep to the saphenous vein. Two of 40 buttons (5%) were placed within the tibial periosteum, and 38 (95%) were subfascial and directly superficial to the periosteum. Four of 40 (10%) limbs revealed a perforation in the saphenous vein from the guidepin. In conclusion, risks to the medial neurovascular structures exist with the medial deployment technique, but they appear to be mitigated compared with previous publications. The necessity of a medial incision to evaluate for soft tissue entrapment may not be necessary in all patients, as this technique appears to be safe, accurate, and reproducible.

Tenosynovial Giant Cell Tumor in the Midfoot Treated With Femoral Head Allograft Reconstruction.

Tenosynovial giant cell tumor (also known as giant cell tumor of tendon sheath or pigmented villonodular synovitis) is a rare soft tissue tumor that arises from the tenosynovium of a tendon sheath or the synovium of a diarthrodial joint. This disease process occurs infrequently in the foot and ankle but can result in significant bone erosion and destructive changes of affected joints. These cases are challenging to treat, because the tumor most commonly presents in young, active patients and can be associated with extensive bone loss. We review a case of tenosynovial giant cell tumor of tendon sheath of the midfoot, which was treated with mass resection, structural femoral head allograft bone grafting, and internal fixation with dorsal plating. The patient had achieved successful bony fusion and acceptable functional outcomes at the final follow-up visit 40 months postoperatively.

Adult-acquired flatfoot deformity.

Adult-acquired flatfoot deformity (AAFD) is a known and recognized cause of pain and disability. Loss of PTT function is the most important contributor to AAFD, and its estimated prevalence is thought to be over 3%. This review aims to summarize the current literature and encompass recent advances regarding AAFD.

Management of acute injuries of the tibiofibular syndesmosis.

The syndesmosis is important for ankle stability and load transmission and is commonly injured in association with ankle sprains and fractures. Syndesmotic disruption is associated with between 5 and 10% of ankle sprains and 11-20% of operative ankle fractures. Failure to recognize and appropriately treat syndesmotic disruption can portend poor functional outcomes for patients; therefore, early recognition and appropriate treatment are critical. Syndesmotic injuries are difficult to diagnose, and even when identified and treated, a slightly malreduced syndesmosis can lead to joint destruction and poor functional outcomes. This review will discuss the relevant anatomy, biomechanics, mechanism of injury, clinical evaluation, and treatment of acute injuries to the ankle syndesmosis.

Branching patterns of the superficial peroneal nerve: implications for ankle arthroscopy and for anterolateral surgical approaches to the ankle.

Ankle arthroscopic procedures offer less postoperative morbidity with faster healing times than open surgical procedures but still have associated risks. Complication rates as high as 17% have been reported. One of the most commonly reported complications is iatrogenic damage to the superficial peroneal nerve, which can result in numbness, tingling, or painful neuralgia. In the present study, we attempted to better assess the location of the superficial peroneal nerve at the ankle to improve preoperative planning and reduce complication rates. Fifty ankle specimens were dissected. A concerted effort was made to classify the location of the superficial peroneal nerve according to the Takao branching pattern, zones of the ankle, and distance to anatomic landmarks. Through our dissections, we found that most ankles have 2 nerve branches at the level of the ankle joint (Takao type II) and that the location of the superficial peroneal nerve branches at the ankle correlated directly with the ankle width. Additionally, 68% of specimens contained a nerve branch located in zone 1, where the anterolateral portal is placed, and 12% had a branch in zone 5, the location of the anteromedial portal site. The results of the present study have confirmed the wide variation in nerve location at the level of the ankle joint and serve to highlight the need for extreme caution during surgical procedures at the ankle.

What are the patterns of prophylactic postoperative oral antibiotic use after foot and ankle surgery?

BACKGROUND: The CDC estimates 23% of healthcare-associated infections to be surgical site infections, with alarming prevalence of antibiotic-resistant organisms. While there is consensus regarding preoperative prophylaxis, orthopaedic surgeons' use of prophylactic postoperative oral antibiotics is less defined. QUESTIONS/PURPOSES: We investigated surgeons' use of prophylactic postoperative oral antibiotics after elective outpatient foot or ankle procedures, identifying (1) frequency of use, (2) regimen preferences, (3) personal indications, and (4) associated experience and demographics. METHODS: Using a cross-sectional survey design, a questionnaire was emailed to all active and candidate members of the American Orthopaedic Foot and Ankle Society. Supplementary questions captured demographic information. We invited 1136 members to participate; 22 addresses produced delivery failure messages, leaving 1114 members as potential participants. After nonresponses and exclusions, 312 (28%) responses were analyzed. Statistical analysis used Pearson's chi-square test, Fisher's exact test, and multivariate regression. RESULTS: The majority (75%) of respondents reported use of prophylactic postoperative oral antibiotics. Most users (69%) prescribed to fewer than 25% of patients, although 16% prescribed for all elective cases. The most frequent regimen was cephalexin 500 mg four times a day (63%) and the most common duration was 5 to 7 days (50%). Surgeons' most common indications were previous infection (71%), medical comorbidities (65%), and previous wound-healing difficulties (56%). Those who do and do not prescribe prophylactic postoperative oral antibiotics showed no difference in surgical site infection rate or any demographic category. CONCLUSIONS: Surgeons' reported use of prophylactic postoperative oral antibiotics after elective foot or ankle surgery was common, without demographic association. Commonalities were identified in antibiotic regimen and personal indications for this practice. Comparative clinical studies are warranted to elucidate the efficacy of prophylactic postoperative oral antibiotics and establish evidence-based guidelines for their use.

Isolated adult Tillaux fracture: a report of two cases.

A fracture of the lateral margin of the distal tibia has commonly been called a Tillaux fracture, which is an avulsion-type fracture that can result from the pull of the anterior inferior tibiofibular ligament. The common mechanism of injury described and observed has been one of external rotation of the foot relative to the tibia. Historically, this fracture pattern has been noted in the pediatric and adolescent populations and classified as a Salter-Harris III fracture through the epiphysis. It has typically occurred in children aged 12 to 14 years and is not commonly seen in adults. We discuss 2 cases of isolated Tillaux fractures in skeletally mature adults, aged 47 and 37 years, a population in which this fracture pattern to our knowledge and after review of the published data has not been described. It is important to recognize these distinct injuries and appropriately treat the pathologic features to prevent further instability and arthritis.

Posterior malleolus fracture.

Posterior malleolus fractures are a common component of ankle fractures. The morphology is variable; these fractures range from small posterolateral avulsion injuries to large displaced fracture fragments. The integrity of the posterior malleolus and its ligamentous attachment is important for tibiotalar load transfer, posterior talar stability, and rotatory ankle stability. Fixation of posterior malleolus fractures in the setting of rotational ankle injuries has certain benefits, such as restoring articular congruity and rotatory ankle stability, as well as preventing posterior talar translation, but current indications are unclear. Fragment size as a percentage of the anteroposterior dimension of the articular surface is often cited as an indication for fixation, although several factors may contribute to the decision, such as articular impaction, comminution, and syndesmotic stability. Outcome studies show that, in patients with ankle fractures, the presence of a posterior malleolus fracture negatively affects prognosis. Notable variability is evident in surgeon practice.

Posterior pilon fractures: a retrospective case series and proposed classification system.

BACKGROUND: Posterior malleolus fractures occur in 7% to 44% of ankle fractures and are associated with worse clinical outcomes. Fractures that involve the posteromedial plafond extending to the medial malleolus have been described previously in small case series. Failure to identify this fracture pattern has led to poor clinical outcomes and persistent talar subluxation. The purpose of this study was to report our outcomes following fixation of this posterior pilon fracture and to describe a novel classification system to help guide operative planning and fixation. METHODS: Eleven patients were identified following fixation of a posterior pilon fracture over a 4-year span; 7 returned at minimum 1-year follow-up to complete a physical examination, radiographs, and RAND-36 (health-related quality of life score developed at RAND [Research and Development Corporation] as part of the Medical Outcomes Study) and American Orthopaedic Foot & Ankle Society (AOFAS) ankle/hindfoot questionnaires. Patient records were reviewed to evaluate for secondary complications or operative procedures. RESULTS: Our mean postoperative AOFAS ankle/hindfoot score was 82. Anatomical reduction of the plafond was noted radiographically in 7 of 11 patients, with the remainder demonstrating less than 2 mm of articular incongruity. Five of 7 patients demonstrated ankle and hindfoot range of motion within 5 degrees of the uninvolved extremity. Four complications required operative intervention; 2 patients reported continued pain secondary to development of CRPS. CONCLUSION: The posterior pilon fracture is a challenging fracture pattern to treat, and it has unique characteristics that require careful attention to operative technique. Our results following fixation of this fracture pattern are comparable with results in the literature. In addition, a novel classification scheme is described to guide recognition and treatment of this fracture pattern. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Patient-Reported Outcome Measurement Information System Measures for Proximal Interphalangeal Joint Arthrodesis in Lesser Toe Deformities.

Although hammertoe (HT) is a common complaint among foot patients, there is little consensus on the best surgical approach for correction. These authors hypothesized that the use of a headless intramedullary screw across both the proximal interphalangeal joint (PIPJ) and distal interphalangeal joint (DIPJ) would decrease many post-surgical complications, such as infection, pain, and mallet toe deformity, found in traditional HT corrective surgical techniques. In this retrospective cohort study, N = 163 adult patients who had undergone DIPJ/PIPJ arthrodesis for HT correction at least 1 year prior to the study were identified. One hundred fifty-nine patients were contacted through REDCap to complete Patient-Reported Outcome Measurement Information System (PROMIS) physical function (PF) and pain interference (PI). Demographic, radiographic, and follow-up data were taken from the electronic medical record (EMR). Analysis was completed with Microsoft Excel; PROMIS PF and PI measures for the 32-person cohort were 45.65 ± 8.26 and 51.65 ± 9.01, respectively. The PF and PI measures had a statistically significant correlation (R2 = 0.71). The 163-person cohort had an overall revision rate of 6.75%, or 11 patients, and an infection rate of 1.23%. This procedure had lower rates of residual pain, infection, mallet toe deformity, and reoperation when compared with current techniques. This study supports the safety and viability of PIPJ/DIPJ arthrodesis using a headless screw for HT correction.Levels of Evidence: Level III Retrospective Cohort Study.

Advances in Diagnosis and Management of Lateral Ankle Instability: A Review of Current Literature.

Lateral ankle sprains and instability are an increasingly identified pain point for patients, accounting for 20 to 25% of musculoskeletal injuries. Lateral ankle injuries are especially concerning given the propensity for patients to develop chronic lateral ankle instability and for the high risk of reinjury on an unstable ankle. With the complex articulation of the tibiofibular syndesmosis, subtalar, and talocrural joints, pinpointing ankle dysfunction remains difficult. Multiple reviews have evaluated management and diagnosis of lateral ankle instability, but with newer treatment options available, a more comprehensive assessment of the current literature was conducted. Although multiple surgical options exist, many nonsurgical functional options have also been developed for patients that may help patients prevent the development of chronic lateral ankle instability. In recent times, many new options have come up, including in-office needle arthroscopy and continual advancements in diagnosis and our understanding of this difficult topic. Multiple reviews have evaluated the management and diagnosis of lateral ankle instability, but with newer treatment options available, a more comprehensive assessment of the current literature was conducted. Given this, this review will help to highlight new diagnostic and nonsurgical therapeutic options for the management of lateral ankle instability.

Use of a Novel Adhesive Suture Retention Device in Non-traumatic Diabetic Lower Extremity Amputations: A Multicenter Case Review.

Background: Amputations in the diabetic foot are commonly associated with complications, including delayed wound healing, surgical site dehiscence, and the need for additional amputations. Use of a novel adhesive suture retention device (ASRD) has been previously shown to support improved linear closure outcomes. The purpose of this retrospective case review was to determine if the adoption of the ASRD in 5 podiatric surgical practices would reduce postoperative complications in patients with diabetes undergoing foot amputations including surgical site dehiscence and the need for additional amputation. Methods: A 5-center retrospective chart review was performed to assess the difference in postoperative surgical site dehiscence and reamputation rates for patients with diabetes undergoing minor and major lower extremity amputations before and after adopting the use of the ARSD. Results: Adoption of the adhesive retention suture device was associated with an overall decrease in wound dehiscence of 81% (P < .01). Additionally, there was an 89% reduction in progression to higher level amputation in the ARSD cohort (P = .015). Conclusions: Utilization of the ARSD decreased the incidence of postoperative wound dehiscence and reamputation in this patient cohort, thus lessening patient morbidity and decreasing the overall cost of care.

Variability in radiographic medial clear space measurement of the normal weight-bearing ankle.

BACKGROUND: Medial clear space (MCS) width on mortise radiographs of the ankle is commonly used by clinicians for determining the competence of the deltoid ligament in the Weber B supination-external rotation ankle fracture. Significant variability exists in the current literature regarding methods of obtaining this measure and definition of a normal measure in comparison with a pathologic state. METHODS: Seventy-three paired bilateral ankle mortise radiographs that were without ankle pathology were retrospectively reviewed. MCS width at two separate locations (oblique and perpendicular) and superior clear space (SCS) were measured on digital radiographs. A Student's t test was used to compare mean values. RESULTS: Mean values (± SD) were 3.2 (± 0.7)~mm for MCS oblique, 2.6 (± 0.7)~mm for MCS perpendicular, and 3.3 (± 0.6)~mm for SCS. A significant difference (p < .001) existed for all three measures between males and females. MCS oblique was statistically different than MCS perpendicular (p < .001) for all patients and for males and females independently. The mean difference between paired bilateral radiographs was 0.3 (± 0.2)~mm for MCS oblique, 0.6 (± 0.6)~mm for MCS perpendicular, and 0.2 (± 0.2)~mm for SCS. CONCLUSIONS: MCS width has variability based on the location chosen for measurement and gender. Contralateral radiographic comparison of MCS should be routinely used to identify pathologic widening versus normal anatomic variation. CLINICAL RELEVANCE: Use of single threshold values for MCS width as an operative indicator may produce a false-positive diagnosis of deltoid incompetence in Weber B supination-external rotation ankle fractures and possibly lead to unnecessary surgery.

Radiographic evaluation of the normal distal tibiofibular syndesmosis.

BACKGROUND: Diagnosis of syndesmotic injuries is primarily based upon the assessment of ankle radiographs. The purpose of our study was to redefine the radiographic relationships of the ankle syndesmosis based on a large series of normal ankle radiographs in living subjects. METHODS: The study involved 392 patients (218 females, 174 males) with ankle radiographs without known clinical or radiographic evidence of abnormality. Eighty-three of the 392 patients had also had normal contralateral radiographs. Tibiofibular overlap and tibiofibular clear space were measured on anteroposterior (AP) and mortise radiographs. The radiographic measurements were used to calculate means, standard deviations, and intra- and interobserver reliabilities, and compare genders and side-to-side radiographs. RESULTS: The mean overlap was 8.3 mm on the AP and 3.5 mm on the mortise while the mean clear space was 4.6 mm on the AP and 4.3 mm on the mortise view. The least amount of overlap on the AP view was 1.8 mm. On the mortise view, there was a subset of patients that had a complete lack of overlap (less than 0 mm) with the greatest gap noted to be 1.9 mm. The greatest clear space on AP was 8 mm and on the mortise was 7.6 mm. Mortise clear space was the most accurate measure when obtaining contralateral radiographs, with a mean side-to-side difference of 0.7 ± 0.7 mm. CONCLUSION: Lack of overlap on the mortise view can represent a normal variant, which has not been definitively reported in prior investigations. CLINICAL RELEVANCE: Our data form the basis for revised radiographic criteria to evaluate the distal tibiofibular syndesmosis which may influence clinical management of these patients.

Salvage of recurrence after failed surgical treatment of hallux valgus.

Recurrence of the deformity is unfortunately a common occurrence following surgical treatment of hallux valgus. The underlying reason for recurrence is multifactorial and includes surgeon's factor, patient's factor, and deformity components that were not addressed at the index procedure. Salvage of recurrence can be challenging for both the patient and the surgeon. Successful treatment requires understanding the underlying reason for the failure of initial treatment and correcting bony alignment, restoring the joint congruity, and balancing soft tissues. We present an algorithmic approach to revision hallux valgus surgery.

Superficial Deltoid Ligament and Deep Deltoid Ligament Play Equally Important Roles in the Stability of Isolated Lateral Malleolus (OTA/AO 44-B1) Fractures: A Biomechanical Study.

OBJECTIVE: To evaluate the individual contributions to stability of the superficial and deep deltoid ligaments in the setting of SER IV ankle fractures. METHODS: Nineteen total cadaveric specimens were used. SER IV injuries were created with the rupture of either the superficial (SER IV-S) (n = 9) or deep deltoid (SER IV-D) (n = 10). These were tested by applying an external rotation force (1 Nm, 2 Nm, 3 Nm, and 4 Nm). Changes in the position of the talus were recorded with a 3D motion tracker. Injury conditions were compared with a 4-step general linear model with repeated measures. Injury condition was also compared with the intact state and to each other using 2-tailed t tests. RESULTS: The general linear model showed that increased loading had a significant effect with axial rotation (P = 0.02) and sagittal translation (P = 0.003). SER IV-S and SER IV-D showed significantly greater instability compared with the intact state in axial rotation (1 Nm, 2 Nm, and 3 Nm). SER IV-S and SER IV-D did not significantly differ from each other. CONCLUSIONS: SER IV fracture patterns can be unstable with isolated injury to either the superficial or deep deltoid. This challenges the notion that deep deltoid rupture is necessary. Further clinical studies would help quantify the consequences of this instability.

Characteristics and Trends of Highly Cited Articles in Calcaneus Fracture Research.

Background: Despite significant effort expended toward exploring fracture patterns, surgical timing, surgical approaches, and possible implants within the calcaneus fracture literature, treatment is still fraught with complications and controversy. This study aims to conduct a citation analysis of the most cited articles related to calcaneus fractures to highlight the most historically influential articles, as well as the more recent breakthrough articles that are leading change within the field. Methods: A literature search was performed via Scopus on September 20, 2021 using the terms "(calcaneus OR calcaneal OR hindfoot) AND (fracture OR injury)" to search "article title, abstract, and keywords" of all primary and review articles. Search results were rigorously reviewed to ensure appropriateness for this study. The 50 highest total cited included articles were analyzed. Title, authors, journal, country of origin, institution, year of publication, citation variables (total citation count, total citation density, citation count from the last 5 years, and 5-year citation density), and level of evidence were collected for each article. One-way analysis of variance with post hoc testing was used to identify differences in citation variables and level of evidence. Pearson correlation was used to directly compare different citation variables. Results: The total citation count average was 178±33, with a total citation density average of 9±2. The year of publication for the 50 articles ranged from 1948 to 2014, with a median year of 1999. Roy W. Sanders was the most productive author in the field, authoring 6 articles and lead authoring 3. The most frequent level of evidence was IV with 19 articles. There was a strong correlation between total citation density and 5-year citation density. The article level of evidence showed no impact on the included measures of an article's influence. Conclusion: This study successfully analyzes and presents the characteristics among the highest cited articles related to calcaneus fractures. The provided characterization of influential works and authors highlights trends, impactful findings, and future areas of focus within calcaneus fracture literature.Level of Evidence: Review Article.

Biologic Augmentation of Tibiotalocalcaneal Arthrodesis With Allogeneic Bone Block Is Associated With High Rates of Fusion.

BACKGROUND: The orthopaedic conditions and systemic comorbidities that occur in patients who require bone block tibiotalocalcaneal (TTC) arthrodesis have made this procedure associated with a higher-than-normal risk of nonunion, graft collapse, hardware failure, and amputation. Here, we present a novel approach to bone block TTC arthrodesis using adjunctive osteoinductive agents and a prolonged course of protected weightbearing to assess if we could improve on historical outcomes. We also evaluated the efficacy of a vascularized medial femoral condyle (MFC) free flap to augment TTC arthrodesis. METHODS: Fourteen adult patients underwent bone block TTC arthrodesis biologically augmented with fresh-frozen femoral head allograft, bone marrow aspirate concentrate, and demineralized bone matrix cortical fibers. Three patients with soft tissue defects underwent vascularized reconstruction with an MFC free flap. Radiographic union, the Foot Function Index (FFI), and PROMIS pain interference (PI), and physical function (PF) scores were assessed at follow-up. RESULTS: TTC fusion was documented on plain radiograph in 13 of 14 patients (92.9%) and CT in 10 of 11 patients (90.9%). Mean time to fusion was 183.2 ± 83.2 days. One patient (7.1%) experienced nonunion and persistent infection requiring amputation. Patients who underwent vascularized bone grafting had significantly shorter time to fusion (112.3 ± 31.7 days vs 204.4 ± 82.7 days, P = .05). Patient-reported outcomes revealed mild to moderate pain and dysfunction after 1 year (mean FFI = 41.0% ± 23.1%, PROMIS PI = 58.3 ± 1.8, PROMIS PF = 39.0 ± 2.2). CONCLUSION: In this relatively small series, the biologic augmentation of bone block TTC arthrodesis with osteoinductive agents and protective weightbearing resulted in excellent rates of fusion, modest pain, and preserved function of the lower extremity in almost all those treated. Osseous healing appears to be enhanced and accelerated with application of an MFC flap. We believe that this approach offers a viable salvage option for these challenging clinical problems. LEVEL OF EVIDENCE: Level IV, case series.

Spring and Deltoid Ligament Insufficiency in the Setting of Progressive Collapsing Foot Deformity. An Update on Diagnosis and Management.

The spring ligament and deltoid ligament are important stabilizers of the medial ankle. Together, they form a complex along the medial ankle and foot that is critical to stability of both the ankle and the medial longitudinal arch. Incompetence of the spring and deltoid ligament is a component of both the early and late stages of progressive collapsing foot deformity. As the importance of this medial ligament complex has been recognized, repair and reconstruction of these ligaments have progressively evolved, initially as separate reconstructions, and more recently as combined techniques.