Clinical tips: retrograde drilling of talar osteochondral defects.

Contemporary methods of bone grafting osteochondral defects, in which the remaining overlying cartilage is relatively well preserved, have inherent problems. The bony defects are often saucer-shaped and the cylindrical graft may not fill the void, leaving areas of cartilage with no underlying scaffold and obviating early weight bearing. Furthermore, to obtain a proper fill of the defect, tamping of the graft can cause excessive pressure and disruption of the overlying cartilage. In an effort to address these concerns, the authors propose the use of a biological viscous paste of calcium sulfate that hardens within 5 minutes when injected in a retrograde fashion into the talus. This confers a mechanical advantage of complete cystic fill of the cyst which allows early weight bearing. Calcium sulfate acts as an osteoconductive material that incorporates into host bone within 8 weeks. Donor site morbidity is eliminated using this system.

Extensive implant reaction in failed subtalar joint arthroereisis: report of two cases.

Foreign body synovitis with extensive granulomatous giant cell reaction to refractile polyethelene debris is a complication of subtalar arthroereisis not previously reported. We present two cases whereby STA-peg implants were used to treat bilateral painful flexible flatfoot deformities in children. Two boys, presented at 7 and 10 years of age, 2 years after STA-peg procedures and tendo-Achilles lengthening for painful flatfeet. They each had minimal subtalar motion and pain at the sinus tarsi. Radiographs demonstrated surgical defects in the calcaneus with surrounding high signal on the magnetic resonance imaging (MRI) in the subchondral bone of the calcaneus and talus. Both patients failed conservative management and had their implants removed with good relief of their pain. Histology was submitted at the time of implant removal. We present the radiographic and pathologic findings seen in these two patients with failed subtalar arthroereisis due to extensive implant reaction. The pathologic process seen in these patients is a previously unreported complication of this procedure. We do not recommend arthroereisis in the treatment of painful flexible flatfoot in children.

The frequency of digital artery resection in Morton interdigital neurectomy.

BACKGROUND: Operative strategies used in resecting the digital nerve in Morton neuroma emphasize retaining the digital artery. Concern over inadvertent resection of the digital vessel has prompted many surgeons to avoid adjacent interdigital neurectomies when more than one nerve is affected. METHODS: The current study examined 674 consecutive pathologic specimens obtained after neurectomy. RESULTS: The digital vessel was identified along with the resected nerve in 39% of specimens. No adverse effect was recorded from these arterial resections. CONCLUSION: Extensive collateralization of digital vessels is hypothesized to account for the lack of adverse sequelae.

Observations on the fibrous retinacula of the heel pad.

BACKGROUND: The original purpose of the study was to clarify whether or not there is continuity of the Achilles tendon and the plantar fascia. Those findings have been previously published. In the course of that study, observations of the anatomy of the retinacular tethers of the heel pad were made. These observations included the discovery of the medial calcaneal retinaculum. METHODS: Ten adult cadaver feet were dissected. A longitudinal midline incision was made along the Achilles tendon and on the plantar surface of the foot. The heel pad was incised and the skin and heel pad were reflected side-to-side to reveal the calcaneal tuberosity. In this way the retinacular tethers of the heel pad could be seen. RESULTS: Two types of retinacular fibers were observed. Abundant small retinacula were seen coming off the plantar fascia and calcaneal tuberosity. Less abundant larger retinacula originated from the calcaneus only. Both types anchored the heel pad by branching into the fibrous stroma of the heel pad. In nine of 10 feet, a much larger retinacular structure was the principle tether of the heel pad to the medial process of the calcaneal tuberosity. We named this the medial calcaneal retinaculum. CONCLUSIONS: The heel pad is anchored by retinacula that vary in number, location, and size. The most consistent and significant tether of the heel pad appears to be the medial calcaneal retinaculum. CLINICAL RELEVANCE: Dislocation of the fat pad of the heel is a relatively rare but potentially devastating injury. An understanding of the anatomical anchoring of the heel pad and its mechanical function can lead to a surgical procedure to restore stability to the heel pad.

Outcomes after standardized screw fixation technique of ankle arthrodesis.

Several methods of obtaining ankle fusion have been described, with numerous studies reporting on patient populations with varied diagnoses and various methods of fixation. This has led to outcome analyses that are difficult to interpret. Our hypothesis is that using a standard method of fusion, without the aid of allograft, a solid ankle fusion can be achieved in patients with end-stage ankle arthritis, and that this outcome can be reflected in standardized outcome tools. Forty-one consecutive ankle fusions in 40 patients were included in our study, with a minimum followup of 3 years. All patients had an ankle arthrodesis using two parallel retrograde 7.3-mm screws and local fibular graft. All but two patients obtained a solid talocrural union (95%), with a mean postoperative improvement in the American Orthopaedic Foot and Ankle Society score of 23 points. Results of our study showed that a simple technique based on sound mechanical and biologic principles can yield excellent outcomes for patients.

Outcomes after interposition arthroplasty for treatment of hallux rigidus.

UNLABELLED: Interposition arthroplasty reportedly improves outcomes after traditional salvage procedures for advanced hallux rigidus. We hypothesized this procedure can provide pain relief and satisfactory function with few complications. We examined 18 patients with severe articular cartilage loss who received 21 interposition arthroplasties. The patients a mean age was 56 years. They had a mean followup of 38 months. All patients had substantial loss of articular cartilage when examined intraoperatively. Patients were evaluated using the American Orthopaedic Foot and Ankle Society and Short Form-36 scores. All 18 patients had pain relief, and 17 of 18 patients said they would have the procedure again. The mean postoperative increase in range of motion of the first meta-tarsophalangeal joint was 37 degrees . The mean American Orthopaedic Foot and Ankle Society and Short Form-36 scores were 78.4 and 96.3, respectively. The complication rate was 6%. Results of our study indicate that interposition arthroplasty relieves pain and restores motion in patients with advanced hallux rigidus and may offer a reliable option to fusing the joint. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series).

An analysis of talar surface area occupied by screw fixation in ankle fusions.

BACKGROUND: Ankle arthrodesis remains the benchmark of treatment for end-stage arthrosis of the ankle joint. Despite that, the incidence of nonunion can be as high as 15%. Various strategies have been used to reduce the incidence of nonunion, including multiple compression screws and larger diameter screws to improve mechanical stability and compression. The space occupied by an increasing amount of hardware across a finite surface area available for fusion has prompted concern that this strategy may be counterproductive and may reduce the biological potential of the construct. The purpose of this study was to look at 40 anatomic sawbone specimens of the ankle to determine the amount of talar surface contact area used by the screw fixation during arthrodesis. METHODS: Four groups were created to examine different techniques for arthrodesis. Simulated ankle arthrodeses were done using two- or three-screw fixation with 6.5-mm and 7.3-mm screws. Hardware was subsequently removed and the surface area used by the passing screws was measured. Total surface areas were calculated for each of the 40 specimens. RESULTS: The maximal surface area of the talus occupied by screws occurred when using three 7.3-mm screws. This configuration used 16% of the possible talar surface area available for arthrodesis. CONCLUSION: The use of additional screw fixation when performing an ankle arthrodesis does not sacrifice a major amount of the tibiotalar contact area and will most likely not affect the biologic environment needed to obtain fusion.

An analysis of outcome measures following the Broström-Gould procedure for chronic lateral ankle instability.

BACKGROUND: The Broström-Gould procedure is a commonly recommended operative treatment for chronic ankle instability. Using standardized physician-based outcome scores, the results of this procedure have been uniformly excellent. Current scoring systems, however, do not adequately evaluate mechanical or functional instability. Therefore, outcome data may suggest greater success than is justified. METHODS: A retrospective review was done of 73 patients who had isolated Broström-Gould repairs of the lateral ankle ligaments. The mean time to followup was 64 months. Both the AOFAS ankle-hindfoot score and the Short Form 36 (SF-36) were used to evaluate outcome. RESULTS: The overall American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 95 of 100 points. Despite that, 17% of patients in the study had functional instability of the ankle that was not reflected in the AOFAS score. The mean physical component score of the SF-36 was 84% and reflected the presence of functional instability. Low correlations were found between the AOFAS ankle-hindfoot score and the SF-36 score. CONCLUSIONS: The current study identified a deficiency in the AOFAS score in evaluating functional ankle stability after the Broström-Gould procedure. A more meaningful analysis of outcomes can be expected using the SF-36 score. The data suggest that greater attention must be paid to functional rehabilitation after ankle stabilization surgery to obtain optimal outcome.

Foot and ankle injuries in the adolescent runner.

PURPOSE OF REVIEW: To evaluate the increase in overuse injuries in the adolescent athlete, specifically sports-related injuries to the foot and ankle of the adolescent runner. Factors affecting these injuries include anatomic considerations, gender, rate of development, growth, training errors, shoe wear, and running surface. RECENT FINDINGS: Most injuries in adolescent runners are overuse injuries rather than sudden traumatic events. Adolescent athletes are as prone as adults to poor form, poor habits, and poor training patterns. In addition, anatomic variants in the hindfoot, midfoot, and forefoot may predispose an athlete to specific injury. SUMMARY: Adolescent running injuries are common and becoming more frequent as trainers and athletes place increasing demands on the growing body. There is no evidence that this increased demand produces long-term adverse effects; however, a significant amount of time can be lost to injuries unless training patterns are constructed to allow for repair of the adolescent athlete.

Physician and patient based outcomes following surgical resection of Haglund's deformity.

Calcaneal ostectomy is the benchmark for definitive surgical treatment in patients with Haglund's syndrome, despite conflicting and unpredictable study results. The current study's hypothesis is that when adequate bone is resected and outcomes are evaluated using validated scores, calcaneal ostectomy can give reliable and predictable results. Thirty six consecutive patients (39 feet) underwent calcaneal ostectomy for Haglund's deformity between 1998 and 2002. All patients were evaluated with the AOFAS score and SF-36v2 questionnaire. The mean time to follow-up was 51 months. The mean AOFAS score following surgery was 86/100 points; the mean SF-36v2 score following surgery was 144/152. Six of the 36 patients interviewed, however, would not recommend the procedure to others, citing mainly prolonged recovery time. Calcaneal ostectomy achieves good-to-excellent results in the treatment of Haglund's deformity when appropriate amounts of bone are excised. However, patients must be made aware of the necessary time to recovery, between 6 months and 2 years.