Strength evaluation of lateral calcaneal wall with circular external fixation application in cadaveric specimens.

Circular external fixation is a useful treatment option for the correction of complex trauma, extremity deformity, osteomyelitis, and reconstruction of the foot and ankle. The goal of the present study was to determine the degrees of bolt rotation required to create enough wire tension to cause structural failure of the lateral calcaneal wall when stressed with both olive and smooth wires in a cadaveric model. Ten fresh, thawed, below-the-knee specimens were tested at the San Diego Cadaveric Academic Research Symposium. The mean bolt rotation required to pull an olive wire through the lateral wall of the calcaneus was 79.8° ± 32.81°, and the mean bolt rotation required to "walk" a skinny wire (narrow diameter) and create 1 mm of cortical bone failure was 50.5° ± 30.91°. The results of the present investigation further define and elucidate the appropriate "Russian tensioning" technique applicable for external fixation of the calcaneus using olive or skinny wires in the case of fracture repair or compression arthrodesis.

Intramedullary Fixation of Distal Fibula Fractures.

BACKGROUND: Ankle fractures pose a unique challenge to the treating orthopedic surgeon. Intramedullary (IM) distal fibula fixation is a relatively newer entity offering a viable option to minimize wound complications while providing similar outcomes. Our study utilizes an IM nail featuring proximal fixation via IM talons ensuring maintenance of fracture reduction this is the largest case series utilizing this novel device assessing time to weight-bearing (WB) and fracture union in addition to the safety and reproducibility of percutaneous reduction. METHODS: A retrospective case series was conducted on 51 ankle fractures treated with a single IM device for lateral malleolar fixation. Postoperative radiographs were assessed, qualifying reductions as good, fair, or poor based on a reduction classification. Patient charts were reviewed for fracture characteristics, reduction method, fracture union, time to WB, and complications. RESULTS: Mean follow-up time was 32.2 weeks; 47 fracture reductions (92%) were classified as good, and 4 (8%) were fair. All but 1 fracture (98%) went onto union. Average time to union was 10.3 weeks. Average time to WB with and without a walking boot was 6.8 and 11.2 weeks, respectively. Two patients experienced painful hardware. One patient had a superficial wound infection. CONCLUSION: When evaluating this novel IM device, fracture union and time to union were found to be acceptable, with minimal wound or other complications. Percutaneous reduction permitted good fracture reduction quality. Consistent time to WB for a variety of fractures was reliably demonstrated following operative fixation with this device, including those in the elderly population. LEVELS OF EVIDENCE: Level IV: Clinical case series.

Early Results of a Novel Intramedullary Fixation Device for Proximal Fifth Metatarsal Fractures.

BACKGROUND: Proximal fifth metatarsal fractures are commonly treated surgically due to their poor healing capacity. While intramedullary screws may be the most popular operative treatment choice, newer fixation methods continue to develop. We present a case series utilizing a novel intramedullary fixation device for proximal fifth metatarsal fractures. To our knowledge, no other study in the literature has assessed the safety and efficacy of this fixation method. METHODS: A retrospective analysis was performed for 16 patients with proximal fifth metatarsal fractures who underwent fixation with the same novel intramedullary device. Patient charts were reviewed for fracture union, plantar fracture gapping, time to weight-bearing, refracture, perioperative complications, and secondary surgeries. RESULTS: Sixteen patients with an average age of 43.3 years underwent fixation with this novel device from 2015 to 2020. Mean follow-up was 32.4 weeks. Fifteen of the 16 patients achieved radiographic union at a mean of 8.9 weeks. One patient suffered a nonunion. Mean time to full weight-bearing in, and out of, a walking boot was 6.4 and 9.8 weeks, respectively, for healed fractures. Mean plantar fracture gap improved from 1.22 mm to 0.88 mm following surgery. There were zero infections, refractures, or hardware complications. Three patients suffered iatrogenic fracture during implant insertion. CONCLUSION: To our knowledge, this is the first report of early results for this novel intramedullary device. Excellent union rates, acceptable time to weight-bearing, and a low complication profile can be achieved. Based on our findings, we propose a safe and effective treatment option for proximal fifth metatarsal fractures. LEVELS OF EVIDENCE: Level IV: Clinical case series.

Arthroscopic treatment of osteochondral lesions of the tibial plafond.

BACKGROUND: Osteochondral lesions of the distal tibial plafond (OLTPs) are an uncommon problem. The purpose of this study was to evaluate clinical outcomes following arthroscopic treatment of OLTPs. METHODS: Retrospective chart review was performed on all patients treated arthroscopically for OLTPs. Treatment consisted of generalized synovectomy followed by curettage of the lesion and microfracture. If a cartilage cap was intact, antegrade drilling was performed. Cystic defects were treated with curettage of the cyst and filling of any defect with bone graft. RESULTS: A total of 13 patients were included. Nine patients had isolated lesions, while four had lesions of the distal tibial plafond and talar dome. Average followup was 156 (range, 38 to 402 ± 117.9) weeks and average patient age was 32.9 (range, 14 to 50 ± 11.8) years. Eleven of 13 patients were available for followup modified AOFAS score. The average preoperative score was 35.2 (range, 24 to 49 ± 7.1). The average postoperative modified AOFAS score was 50.4 (range, 33 to 56 ± 7.6). There were four patients (30.8%) with a poor outcome. CONCLUSION: OLTPs can be challenging to treat. Arthroscopic treatment can lead to improved outcomes. However, the higher incidence of poor outcomes in our series may indicate less predictability in the treatment of OLTPs and that outcomes may not be equivalent to previous reported studies on OLTPs or osteochondral lesions of the talus.

Direct Plantar Approach to Plantar Plate Repair and Associated Wound Complications.

BACKGROUND: Lesser toe metatarsophalangeal joint (MTPJ) instability, secondary to plantar plate tear, has been the focus of numerous recent publications, the majority reporting on repair through a dorsal approach. A plantar approach has been described with the advantage of direct ligamentous repair or repair to bone, which follows conventional techniques employed throughout the body. Previous clinical studies have shown success in deformity correction and the longevity of both approaches. The proponents of the dorsal approach advocate that indirect repair of the plantar plate avoids perceived risks of complications with a plantar incision without evidence of superior outcomes. The purpose of this study was to investigate the safety and efficacy of the direct plantar approach to plantar plate repairs (PPRs) by reporting the rate of specific complications in a large clinical series. METHODS: This was the institutional review board (IRB) approved retrospective study of 204 PPRs in 185 patients (194 lesser MTP, 10 hallux MTP) with an average age of 56 and a mean body mass index (BMI) of 28. Surgical technique involved repair with absorbable braided suture (88%) versus suture anchor (12%) with or without MTPJ pinning (80%). Mean follow up was 53 weeks (range 5-170). Patients were screened for associated risk factors, including diabetes mellitus (8%), tobacco use (5%), neuropathy (1%), and additional concurrent procedures (96%). Complications were defined as superficial or deep infection, painful scars, and reoperation. Analysis was conducted using the Wilcoxon-Mann-Whitney test or Fisher's exact tests for continuous and categorical variables, respectively. Risk factors were analyzed using univariate logistic analysis to produce odds ratios (OR) with a 95% confidence interval (CI) and an inclusion criterion of a P-value, P > .2 for multivariate analysis as determined by Wald tests (significance at P < .05 for final modeling). RESULTS: Overall, there were 31 total complications (15%) demonstrated by 14 superficial infections (6.8%) and 17 painful scars (8.3%) along with three reoperations (1.4%). All reoperations were performed for deformity or instability, not scar revision. There were no deep infections. No increased odds of complications were found with suture anchor repair, MTPJ pinning, neuropathy, or diabetes. Patients that used tobacco had 7.5 (CI 1.66, 34.06) the odds of developing any wound complication compared with nonsmokers. Tobacco use was also found to significantly increase the odds of superficial infection by 9.8 (CI 2.08, 46.15). There was no increase in painful scars or reoperation in tobacco users. This study did not find an increased complication rate with additional ipsilateral procedures performed at the time of surgery. CONCLUSION: To our knowledge, this is the largest study evaluating the direct plantar approach to PPR as well as the evaluation of associated complications with the plantar incision. With low complication and minimal reoperation rates, the results of this study have demonstrated the clinical viability of plantar-based incisions. Previous studies have demonstrated the success of PPR and correction of deformity with a direct approach. This case series further demonstrates the safety and efficacy of plantar-based incisions, particularly for direct PPRs. LEVEL OF EVIDENCE: IV Retrospective Case Series. CATEGORY: Lesser Toes.

Does fresh osteochondral allograft transplantation of talar osteochondral defects improve function?

BACKGROUND: Fresh osteochondral allograft transplantation can be used to replace talar osteochondral defects (OCDs) with single bulk osteochondral graft. While limited studies report improvement of function, improvement in quality of life and radiographic durability is unknown. QUESTIONS/PURPOSE: We therefore determined if this technique improved function, increased quality of life, and provided durable graft stability radiographically and by MRI. PATIENTS AND METHODS: We prospectively followed 19 patients (19 OCDs). We excluded seven patients (four with insufficient followup, two who were lost to followup, and one with graft failure), leaving 12 patients with a minimum followup of 2 years (average, 3.3 years; range, 2.0-4.6 years). Functional and quality of life outcomes were quantified using the American Orthopaedic Foot and Ankle Society (AOFAS) score and the SF-12 Health Survey. Graft incorporation and stability were assessed through radiographs and MRI. RESULTS: Mean total AOFAS scores (61±9 to 79±6), pain subscores (17±8 versus 26±5), and function subscores (34±3 versus 42±4) improved from preoperatively to last followup. We observed no improvements of the physical and mental health components of the SF-12 Health Survey from preoperatively to last followup. At last followup, three of the 12 grafts had radiolucencies, four had edema, one failed to incorporate, and none had subsidence. One of the 19 patients in the overall series underwent graft revision. CONCLUSIONS: Patients with talar OCDs can expect functional improvement after this technique. The majority will have stable grafts at least short term. Larger studies with longer followup are needed to determine if this procedure substantially improves quality of life, if graft radiolucencies and edema have any long-term implications, and whether the grafts are durable. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Correction of rigid equinovarus deformity using a multiplanar external fixator.

BACKGROUND: The rigid equinovarus foot deformity is a challenging condition treated by the orthopaedic foot and ankle surgeon. Rapid surgical correction of the deformity may lead to skin and neurologic complications. Gradual correction of the deformity with a multiplanar external fixator may decrease these complications. The purpose of this study was to present the results of a group of patients with rigid equinovarus deformities corrected using a multiplanar external fixator. MATERIALS AND METHODS: We retrospectively reviewed the results of correction of a rigid equinovarus deformity using multiplanar external fixation in a small group of patients. All patients underwent open Achilles lengthening, posterior capsule release, tibialis posterior tendon lengthening, flexor digitorum longus and flexor hallux longus lengthening, followed by application of a multiplanar external fixator with gradual correction of the deformity over a period of several weeks. Preoperative and postoperative deformity and AOFAS ankle-hindfoot scores were assessed. RESULTS: A total of eight rigid equinovarus deformities in six patients were treated with a multiplanar external fixator. The average patient age at the time of surgery was 37.2 (range, 17 to 59 ± 15.0) years. Causes of the deformity included trauma in three patients, traumatic brain injury in two patients, and long-standing rheumatoid arthritis in one patient. The average preoperative AOFAS ankle-hindfoot score was 28.3 (range, 12 to 38 ± 7.7). The average postoperative AOFAS ankle-hindfoot score was 68.1 (range 38 to 86 ± 15.5) at an average followup of 71.9 (30 to 120 ± 36.2) weeks. All deformities were gradually corrected to a plantigrade foot using a multiplanar external fixator over an average time of 5 (range, 4 to 6 ± 0.8) weeks. After correction of the deformity, the external fixator was left in place for a time period equal to or twice the length of time it took to achieve correction. The average duration of external fixation was 10.8 (range, 8 to 16 ± 2.8) weeks. Seven of eight deformities maintained correction at final followup. There was one case of recurrence. CONCLUSION: Correction of a rigid equinovarus deformity using a multiplanar external fixator was a viable treatment option. It allowed for correction of the deformity in a controlled manner, helping to reduce the risk of neurovascular complications that may result from single stage surgical correction. The risk of wound complications still exists with the correction of such a complex deformity.

Osteochondral lesions of the talus: predictors of clinical outcome.

BACKGROUND: Osteochondral lesions of the talus (OLT) are a common and challenging condition treated by the orthopedic foot and ankle surgeon. Multiple operative treatment modalities have been recommended, and there are several factors that need to be considered when devising a treatment plan. In this study, we retrospectively reviewed a group of patients treated operatively for osteochondral lesions of the talus to determine factors that may have affected outcome. METHODS: A retrospective chart review of clinical, radiographic and operative records was performed for all patients treated for OLTs via marrow stimulation technique. All had a minimum followup of 6 months or until return to full activity, preoperative magnetic resonance imaging (MRI) of the OLT to determine size, and failure of nonoperative treatment. RESULTS: A total of 130 patients were included in the study. This included 64 males and 66 females. The average patient age at the time of surgery was 35.1 +/- 13.7 (range, 12 to 73) years. The average followup was 37.2 +/- 40.2 (range, 7.43 to 247) weeks. The average size of the lesion was 0.84 +/- 0.67 cm2. There were 20 lesions larger than 1.5 cm2 and 110 lesions smaller than 1.5 cm2. There were 113 contained lesions and 17 uncontained lesions. OLTs larger than 1.5 cm2 and uncontained lesions were associated with a poor clinical outcome. CONCLUSIONS: The treatment of osteochondral lesions of the talus remains a challenge to the foot and ankle surgeon. Arthroscopic debridement and drilling will often provide satisfactory results. However, larger lesions and uncontained lesions are often associated with inferior functional outcomes and may require a more extensive initial procedure.

Percutaneous bipolar radiofrequency microdebridement for recalcitrant proximal plantar fasciosis.

Success rates for traditional methods of surgical intervention for chronic plantar fasciosis are low, and associated with high rates of complications and long recovery times. The purpose of this prospective case series was to assess the effectiveness of percutaneous bipolar radiofrequency microfasciotomy for the treatment of recalcitrant proximal plantar fasciosis in 21 patients. The mean preoperative American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score was 22.10 ± 12.96 (out of a possible 68 points) and the mean postoperative AOFAS hindfoot score was 59.57 ± 13.23 points, and this difference was statistically significant (P < .0001). A total of 7 (33.33%) patients experienced satisfactory pain relief within 1 to 4 weeks and 10 (47.62%) did so within 1 to 4 months, whereas 2 (9.52%) patients required longer than 4 months, and 2 (9.52%) others never attained satisfactory relief of symptoms. Fourteen (66.67%) patients subjectively rated their outcome as excellent, 4 (19.05%) as good, 1 (4.76%) as fair, and 2 (9.52%) as poor. One (4.76%) patient experienced iatrogenic flexor hallucis longus tendonitis. The results of this clinical investigation indicate that bipolar radiofrequency microdebridement plantar fasciotomy safely alleviates recalcitrant heel pain. The technique is minimally invasive and simple to perform, and it spares the overall integrity of the plantar fascia without being associated with undue complications.

Retrograde intramedullary nail arthrodesis for avascular necrosis of the talus.

BACKGROUND: Avascular necrosis (AVN) of the talus from any etiology is a devastating pathology. There are few salvage options available and controversy exists as to the surgical management for patients with talar AVN. The authors present their results of tibiotalocalcaneal arthrodesis with a retrograde nail. MATERIALS AND METHODS: A comprehensive chart and radiographic review was pulled from our database for patients with AVN of the talus, who were treated by tibiotalocalcaneal fusion with retrograde intramedullary nail. Primary outcome was union, with time to clinical union as a secondary endpoint. RESULTS: Fourteen patients were included. The average age at surgery was 47.4 ± 12.8 years, there were nine female patients, and the average Body Mass Index was 33.5 ± 6.0. Surgical risk factors included two patients who smoked, one was diabetic, and one had a preoperative ulceration. The average time to partial weightbearing was 70.6 ± 25.4 days, and the average time to full weightbearing was 100.6 ± 35.5 days. Four patients had postoperative complications, while no patients required major revision surgery. Twelve patients went on to solid fusion, while two went on to a stable, braceable pseudoarthrosis. Eight patients were able to return to shoes, and eight were able to walk unaided at final followup. CONCLUSION: Salvage of talar AVN is possible by tibiotalocalcaneal arthrodesis with an intramedullary nail. Physicians may offer this as a salvage option to patients with a high likelihood of successful fusion.

The midfoot sprain: a review of Lisfranc ligament injuries.

The subtle clinical and radiographic findings of an unstable Lisfranc ligament injury can be easily misdiagnosed as a stable midfoot sprain. Appropriate treatment ranges from conservative management to surgery, depending on the extent of ligament disruption and subsequent joint instability. Initial evaluation with non-weight bearing radiographs is often normal in unstable injuries. The results of missed or inappropriately treated Lisfranc injuries are poor. Chronic joint instability can lead to persistent pain, degenerative joint disease, and decreased functional capacity. Inability to return to previous levels of activity may result from painful midfoot arthritis. It is important to have a high index of suspicion for unstable Lisfranc injuries in patients who present with midfoot pain after low-energy injuries. Stress radiographs and magnetic resonance imaging can help differentiate between stable and unstable ligament sprains. Referral to an orthopedic surgeon is appropriate for injuries that result in joint diastasis. Long-term outcomes are optimized by early anatomic reduction.

Peroneal tendon injuries.

Peroneal tendon injuries are underdiagnosed and should be considered in every patient who presents with chronic lateral ankle pain. Ankle sprains are common, and up to 40% of affected individuals experience subsequent chronic ankle pain. Identifying the source of chronic ankle pain can be difficult because of the large number of possible causes. The peroneal tendons are the primary evertors of the foot and function as lateral ankle stabilizers. A careful physical examination, along with a thorough patient history and imaging studies, are critical in arriving at an accurate diagnosis. Understanding the anatomy of the peroneal tendons and knowledge of current treatment approaches for peroneal tendon tears, subluxation and dislocation of the tendons, and peroneal tenosynovitis are of great importance in achieving a favorable outcome. Low-demand patients do well with a nonsurgical approach; high-demand patients may benefit from surgery.

Transosseous fixation of the distal tibiofibular syndesmosis: comparison of an interosseous suture and endobutton to traditional screw fixation in 50 cases.

UNLABELLED: In this prospective cohort study, we compared screw fixation to interosseous suture with endobutton repair of the syndesmosis. Outcomes of interest included preoperative and postoperative modified American Orthopedic Foot and Ankle Society (AOFAS) hindfoot and ankle scores, and Short Form-12 health status scores, as well as radiographic measurements and the time to full weight bearing. Mean averages and ranges were calculated for numeric variables, and outcomes for each fixation group were compared statistically with Student t test. The cohort consisted of 50 patients; 25 in the screw fixation group and 25 in the interosseous wire with endobuttons group. The mean patient age was 34.68 (15 to 55) years in the interosseous suture endobutton group and 36.68 (17 to 74) years in the screw group, and the mean follow-up was 10.78 (range 6 to 12) months in the interosseous suture endobutton group, and 8.20 (range 4 to 24) months in the screw group. No statistically significant differences (P < or = .05) were noted in regard to age, follow-up duration, time to postoperative weight bearing, or subjective outcome scores between the fixation groups; although statistically significant improvements were noted in the subjective scores for each fixation group between the preoperative and postoperative measurements. The results of this study indicate that the interosseous suture with endobuttons is a reasonable option for repair of ankle syndesmotic injuries, and may be as effective as traditional internal screw fixation. LEVEL OF CLINICAL EVIDENCE: 2.

Minimally Invasive Retrograde Method of Harvesting the Flexor Hallucis Longus Tendon: A Cadaveric Study.

BACKGROUND: Use of the flexor hallucis longus (FHL) tendon is well described for several tendon augmentation procedures. Harvesting the FHL through an open medial approach is commonly done, but is associated with anatomic risks. Recently, several authors have described a minimally invasive (MI) technique to harvest the FHL tendon utilizing a hamstring tendon stripper commonly used in ACL reconstruction. The purpose of this study was to evaluate the safety and effectiveness of harvesting the FHL tendon using this novel minimally invasive retrograde approach. METHODS: The FHL tendon was harvested through a transverse plantar incision over the interphalangeal joint of the great toe in 10 fresh-frozen cadaver lower extremities. A lateral-based incision for peroneal tendon repair was made and the FHL was retrieved. Tendon length, complications, and interconnections between the FHL and flexor digitorum longus (FDL) were recorded and classified. The specimens were then dissected by a single surgeon in a standardized fashion, and damage to any surrounding structures was recorded. RESULTS: The average length of the FHL tendon from the distal stump to the first intertendinous connection was 13.3 cm (range 8.8-16 cm, SD 2.3 cm). Eight cadavers demonstrated Plaass type 1 interconnections whereas 2 demonstrated type 3. There was no injury to the medial and lateral plantar arteries and nerves, plantar plate, or FDL tendons. One FHL tendon was amputated at the level of the sustentaculum during graft harvest. No injury of the medial neurovascular structures occurred with retrieval of the FHL tendon through the lateral incision. CONCLUSIONS: We found that care must be taken when approaching the sustentaculum with the tendon harvester in order to avoid amputation of the graft against a hard bony endpoint. Additionally, flexion and extension of the lesser toes could aid in successful tendon harvest when tendon interconnections were encountered. CLINICAL RELEVANCE: Using this MI technique appears to be a safe and effective way to obtain a long FHL tendon graft for tissue augmentation.

Treatment of syndesmotic disruptions with the Arthrex Tightrope: a report of 25 cases.

BACKGROUND: The complexity of syndesmotic injuries, often with both bone and soft tissue injury mandates an expeditious diagnosis and treatment to avoid unfavorable long term outcomes. Various methods of fixation of the syndesmosis have been reported. We present the largest series evaluating the Arthrex Tightrope for management of syndesmotic injuries. MATERIALS AND METHODS: Twenty-five patients with disruption of the distal tibiofibular articulation underwent treatment with an Arthrex Tightrope. In 21 cases, a single tightrope was placed, and in four cases, two tightropes were utilized. Associated ankle fractures were treated using proper AO technique. Those patients with diabetes and/or neuroarthropathic changes foot or ankle were not included in this study. Postoperative evaluation parameters included radiographic measurements, a modified AOFAS scoring system and SF-12. RESULTS: Average followup was 10.8 months. The mean time to full weightbearing was 5.5 (range, 2 to 8) weeks. Postoperative radiographic analysis of the mean distance from the tibial plafond to the placement of the tightrope(s), medial clear space, average postoperative tibiofibular overlap and the mean tibiofibular clear space demonstrated no evidence of re-displacement of the syndesmotic complex at an average of 10.8 (range, 6 to 12) months. The modified AOFAS hindfoot scoring scale and SF-12 both demonstrated significant improvements; preoperative values were assessed in the office with the first patient visit as they are incorporated into the patient intake form that each patient fills out at the initial visit. CONCLUSION: Utilization of the tightrope in diastasis of the syndesmosis should be considered as a good option. The method of placement is quick, can be minimally invasive, and obviates the need for hardware removal. In this series, it maintained excellent reduction of the syndesmosis.

Interpositional arthroplasty of the first MTP joint using a regenerative tissue matrix for the treatment of advanced hallux rigidus.

BACKGROUND: Treatment options are limited for young and active patients with hallux rigidus of the first metatarsophalangeal (MTP) joint. Soft-tissue interpositional arthroplasty is a promising alternative. METHODS: The surgical technique for interpositional arthroplasty utilizing a human acellular dermal regenerative tissue matrix as a spacer is described. A retrospective review of a consecutive series of the first nine patients with Coughlin grade 3 halux rigidus who underwent this procedure is presented. Five patients were female and four were male, with a mean age of 53.3 years, a mean body mass index of 28.6, and a mean duration of symptoms of 3.1 years. RESULTS: The mean length of followup was 12.7 months, with no reported complications or failures. The mean total AOFAS score and pain sub-score were significantly higher at the most recent followup (87.9 and 34.4, respectively) versus preoperatively (63.9 and 17.8, respectively). CONCLUSIONS: These excellent early results and lack of complications may be due to the minimal bone resection associated with the procedure. This technique does not require autograft harvesting, is bone-sparing by preserving the plantar plate, and maintains the natural intrinsics of the joint by preserving its associated tendons and the FHB insertion. The sesamoid articulation also is resurfaced. Although further followup is needed, this technique may offer the young and active patient with advanced hallux rigidus an opportunity to maintain an active lifestyle, while retaining the possibility for more surgical options should the condition progress.

First Metatarsal Head Osteochondral Defect Treatment With Particulated Juvenile Cartilage Allograft Transplantation: A Case Series.

BACKGROUND: Focal damage to articular cartilage, also called an osteochondral defect (OCD), can be a cause of pain and decreased range of motion. Recent advancements have led to transplantation techniques using particulated juvenile articular cartilage allograft. This technique has been applied to the first metatarsal head to a very limited degree, with no published results to our knowledge. The aim of this study was to review the clinical results of patients who underwent particulated juvenile cartilage allograft implantation for first metatarsal head OCDs. METHODS: We performed a retrospective consecutive case series study. Nine patients, at an average age of 41 years, were treated for symptomatic focal osteochondral defects of the first metatarsal head with particulate cartilage grafting from 2010 to 2016. Patients were contacted by phone to assess interest in returning to the office for follow-up, where weightbearing radiographs of the foot were obtained and a foot examination was performed. RESULTS: At an average follow-up of 3.3 years, 7 of 9 patients reported no pain with recreational activities and no patient required further operations. This patient cohort was physically active, with 6 of 9 listing running as a regular activity. The average overall American Orthopaedic Foot & Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scale questionnaire score was 85 (maximum 100), AOFAS pain 35.6 (maximum 40), and AOFAS function 40.1 (maximum 45). Patient satisfaction surveys correlated with the AOFAS scores and revealed that 7 of 9 patients were very satisfied with their results, 1 was satisfied, and 1 patient was very dissatisfied. CONCLUSION: Particulated juvenile cartilage allograft transplantation is a promising treatment option for symptomatic first metatarsophalangeal focal articular cartilage lesions. Further study is needed to demonstrate which lesions respond better to this type of cartilage graft versus traditional marrow-stimulating procedures. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Cross-Sectional Analysis of the Distal Fibular Intramedullary Canal: A Cadaveric Evaluation.

Fractures of the distal fibula secondary to rotational ankle injuries are one of the most common injuries requiring surgical intervention. The aim of this study was to describe the anatomy of the distal fibular medullary canal as a means of aiding in surgical management with an intramedullary device. Twenty fresh cadaveric below-knee specimens (group 1, 10 in 2015, group 2, 10 in 2016) were dissected to expose the distal fibular. Fifteen (10 mm each) segments were sectioned with a sagittal saw from the distal tip proximally and measured with a digital caliper. In group I, the widest and narrowest fibular diameter was at the 20-mm interval (mean 15.02 mm) and 90-mm interval (mean 3.51 mm), respectively. From 70 to 120 mm, the mean diameter was less than 4.0 mm. In group 2, the widest and narrowest diameter was at the 20-mm interval (mean 15.05 mm) and 100-mm interval (mean 4.33 mm), respectively. From 70 to 140 mm, the mean diameter was less than 5.0 mm. The combined mean diameter at the 60- to 80-mm intervals were 4.99 ± 1.70, 4.35 ± 1.63, and 4.02 ± 1.35 mm, respectively. Based on our investigation, we propose an intramedullary device diameter of 4.5 to 5.0 mm in diameter with a length of 60 to 80 mm may provide most appropriate bony purchase to achieve acceptable cortical contact for expected osseous compression. LEVELS OF EVIDENCE: Level IV: Cadaveric case series.

Anatomic Structures at Risk When Utilizing an Intramedullary Nail for Distal Fibular Fractures: A Cadaveric Study.

BACKGROUND: Retrograde intramedullary fibular nail fixation is being utilized with increasing frequency, particularly in patients at higher risk of wound complications. The purpose of this anatomic study was to assess the relative risk to nearby anatomic structures when implanting a contemporary retrograde locked intramedullary fibular nail. METHODS: Ten human cadaveric lower extremities were instrumented with a fibular nail. The cadavers were dissected. The shortest distance, in millimeters (mm), between the site of procedural steps and nearby named structures of interest (ie, sural nerve, superficial peroneal nerve, and the peroneal tendons) was measured and recorded. Levels of risk were assigned based on observed distances as high (0 to 5 mm), moderate (5.1-10 mm), and low (greater than 10 mm). RESULTS: The peroneus brevis (PB) tendon was found to be less than 5.0 mm from the distal skin incision in all specimens. When reaming and inserting the nail through the distal fibula aperture, the PB was less than 5.0 mm in 6 specimens. The peroneus longus tendon was at moderate to high risk when inserting both the proximal and distal syndesmotic screws in 9 specimens. The superficial peroneal nerve was at high risk when inserting an anterior to posterior distal locking screw in 7 specimens. The sural nerve was at low risk for all procedural steps. No structures were violated or damaged during any portion of the fibular nail instrumentation. CONCLUSION: The peroneal tendons and superficial peroneal nerve were at the highest risk; however, no structures were injured during instrumentation. CLINICAL RELEVANCE: The current findings indicate that strict adherence to sound percutaneous technique is needed in order to minimize iatrogenic damage to neighboring structures when performing retrograde locked intramedullary fibular nail insertion. This includes making skin-only incisions, blunt dissection down to bone, and maintaining close approximation between tissue protection sleeves and bone at all times.

Lower-extremity amputations in association with diabetes mellitus.

Aksoy and coworkers [39] found that a multidisciplinary diabetic foot care team can help decrease the rate of major amputations and improve tha patients' quality of life. Multidisciplinary care also includes proper patient education, which can help patients with diabetes mellitus control factors that can lead to complications, such as high blood glucose, high blood pressure, and increased lipid levels. The American Diabetes Association reports that such comprehensive foot care programs can reduce lower-extremity amputation rates among diabetic patients as much as 45% to 60% [1].