Double Versus Triple Arthrodesis Fusion Rates: A Systematic Review.

Hindfoot arthrodesis is often required for end-staged deformities, such as posterior tibial tendon dysfunction, osteoarthritis, or rheumatoid arthritis. Although the need for hindfoot arthrodesis is generally accepted in severe deformities, there is a debate whether a double or triple arthrodesis should be performed. The aim of our systematic review is to review the fusion rates and mean time to fusion in double and triple arthrodesis. A total of 184 articles were identified using the keyword search through the database of articles published from 2005 to 2017. After review by 3 physicians, a total of 13 articles met the eligibility criteria. The reason for double or triple arthrodesis within the studies were posterior tibial tendon dysfunction, tarsal coalition, degenerative joint disease, osteoarthritis, rheumatoid arthritis, Charcot Marie Tooth, Multiple Sclerosis, Polio, neuromuscular disorder, cerebral palsy, acrodystrophic neuropathy, clubfoot, post-traumatic, and seronegative arthropathy (spondyloarthritis). Within these 13 studies, there were a total of 343 (6-95) subjects extremities operated on. The overall fusion rate for double arthrodesis was 91.75% (289/315) compared to 92.86% (26/28) triple arthrodesis fusion rate, p value .8370. The mean time to fusion for double arthrodesis was 17.96 ± 7.96 weeks compared to 16.70 ± 8.18 weeks for triple arthrodesis, p value = .8133. There are risks associated with triple arthrodesis including increased surgical times, lateral wound complications, residual deformity, surgical costs and peri-articular arthritis. Given the benefits of double arthrodesis over triple arthrodesis and the nearly equivalent fusion rates and time to fusion, double arthrodesis is an effective alternative to triple arthrodesis. The authors of this systematic review recommend double arthrodesis as the hindfoot fusion procedure of choice.

Outcomes Following Open Reduction Internal Fixation of Ankle Fractures (ORIF) By Podiatric Surgeons.

Open reduction internal fixation of closed ankle fractures is a common procedure performed by podiatric surgeons. This is the first study to specifically evaluate complication rates of this procedure among podiatric surgeons using a large patient cohort. The rates of podiatric surgical complications were also compared to the complication rates reported in the orthopedic literature. There was no significant difference between podiatric surgeons and orthopedic surgeons with regards to surgical site infection. However, complication rates, including 1-year postsurgery deep vein thrombosis (DVT), malunion, and unplanned revision surgery within 90-day, were lower in our study, compared to the average rates reported in the orthopedic literature. The authors believe that the most important determinant for post ankle surgical complications is related to surgical volume and experience, rather than professional degree type.

Lateral Column Lengthening for Revision Triple and Double Arthrodesis and Severe End-Stage Flatfoot Deformity.

Few options exist for the treatment of revision and severe cases of end-stage flatfoot deformity. Triple arthrodesis or medial-approach double arthrodesis have been the standard but often do not provide enough correction of the deformity. Lateral column lengthening is a powerful procedure performed either with an Evans calcaneal osteotomy or calcaneocuboid distraction arthrodesis that can be used as an adjunct in realigning the flatfoot. We performed a retrospective radiographic review and looked at 11 consecutive cases of patients who underwent hindfoot arthrodesis with a lateral column lengthening procedure. We matched these patients with 11 control patients who underwent isolated medial-approach double arthrodesis. For the patients who underwent a lateral column lengthening procedure, we found a significant improvement in calcaneal inclination angle (p = .001) and greater correction in talar declination angle, cuboid abduction angle, and talocalcaneal angle when compared with the control group. Lateral column lengthening is a useful adjunct to hindfoot arthrodesis in the correction of revision and severe end-stage flatfoot deformity.

Outcomes of Hindfoot Arthrodesis Supplemented With Bioactive Glass and Bone Marrow Aspirate: A Retrospective Radiographic Study.

Foot and ankle surgeons continue to explore bone graft alternatives that will be comparable to the reference standard of autologous bone. The purpose of the present study was to consider the outcomes of hindfoot arthrodesis supplemented with bioactive glass in patients at risk of delayed union and nonunion. We performed a retrospective radiographic review of 29 consecutive patients (48 joints) who had undergone arthrodesis of ≥1 joint of the hindfoot (ankle, subtalar, talonavicular, calcaneocuboid). All patients included in the present study had a minimum of 1 documented risk factor for osseous nonunion (history of previous nonunion, trauma, smoking, diabetes, Charcot arthropathy, obesity, age >65 years at surgery). The patients were followed up for a minimum of 24 weeks or until radiographic healing had been achieved. We found 12 (25.0%) nonunions across all 48 joints supplemented with bioactive glass. We found 4 (16.7%) nonunions in the subtalar joint, 1 (11.1%) in the calcaneocuboid joint, and 1 (11.1%) in the talonavicular joint. We found that hindfoot arthrodesis procedures supplemented with bioactive glass resulted in an incidence of union comparable to that with autograft and other bone graft substitutes.

Comparative Nonunion Rates in Triple Arthrodesis.

The contemporary literature is unclear regarding the joint that is most "at risk" to yield a nonunion in the performance of triple arthrodesis of the foot. There is also a debate regarding the best methods of joint preparation. A retrospective radiographic review was conducted of all primary triple arthrodeses performed within in a Northern California health maintenance organization between January 2007 and June 2013. Data documenting joint preparation techniques were collected, and postoperative imaging was reviewed to measure time to osseous union. Patient demographics were also collected. One hundred fifty-two patients (157 procedures) met the inclusion criteria. The overall nonunion rate for triple arthrodesis in this series was 29.9% (47/157). The nonunion rate of the talonavicular joint was 20.4% (32/157); the nonunion rate of the calcaneocuboid joint was 17.2% (27/157); and the nonunion rate of the subtalar joint was 8.9% (14/157). In conclusion, we found the most likely joint to obtain nonunion during triple arthrodesis was the talonavicular joint. Furthermore, the most efficacious joint preparation technique was a combination joint resection or curettage with fish scaling.

Arthroscopic Medial Approach for Modified Double Arthrodesis of the Foot.

The single medial incision subtalar joint and talonavicular joint arthrodesis has been shown to be a useful alternative for the correction of hindfoot valgus deformity. We describe an arthroscopic method of joint preparation using this approach. The present case report included 6 consecutive patients aged 35 to 72 (mean ± standard deviation 55.8 ± 15.54) years (4 males [66.7%] and 2 females [33.3%]), who had undergone the medial approach for modified double arthrodesis of the foot. Of the 6 patients, 3 (50.0%) had undergone arthroscopic joint preparation and 3 (50.0%) traditional (manual) joint preparation. Osteobiologic agents were used in all patients. We found a shorter tourniquet time for the patients who had undergone an arthroscopic approach, with a mean of 110 ± 7.21 minutes, compared with a traditional joint preparation, with a mean of 121.3 ± 8.08 minutes. We also found a shorter time to radiographic union in the patients who had undergone an arthroscopic approach, all of whom showed signs of union at 6 weeks. Only 2 of the 3 patients in the traditional joint preparation group had achieved union at a mean of 10 ± 2.83 weeks, with 1 case resulting in nonunion. This technique could be a viable alternative to traditional methods of joint preparation by decreasing the operative time and improving the union rates.

Comparison of Medial Malleolar Fracture Healing at 8 Weeks After Open Reduction Internal Fixation Versus Percutaneous Fixation: A Retrospective Cohort Study.

Unstable medial malleolar fractures are treated with either standard open reduction internal fixation (ORIF) or a percutaneous approach. The percutaneous approach avoids the potentially excessive soft tissue dissection associated with an open approach but can also result in inadequate anatomic reduction. No studies have compared the incidence of radiographic healing of medial malleolar fractures between an open approach and percutaneous fixation. A retrospective comparative study was performed at a single institution across multiple sites. Electronic medical records and digital radiographs were reviewed for 845 patients who had undergone either ORIF or percutaneous screw fixation (PSF) of a medial malleolar fracture. The interval to fracture healing was measured. Logistic regression analysis was used. Of the 490 included patients, 458 (93.44%) underwent standard ORIF and 32 (6.53%) underwent PSF. Patients who underwent ORIF were 5 times more likely to have a healed fracture at 8 weeks than were patients who had undergone PSF (p < .001). Compared with standard ORIF, PSF of medial malleolar fractures leads to an increased risk of an unhealed fracture at 8 weeks. This was likely due to a combination of soft tissue interposition within the fracture site and inadequate fluoroscopic reliability, leading to poor anatomic reduction and inaccurate fixation.

A Multicenter, Retrospective Study of Early Weightbearing for Modified Lapidus Arthrodesis.

The modified Lapidus arthrodesis is a long-established surgical technique for management of hallux valgus that provides reproducible results and quality patient outcomes. The data from 367 consecutive patients undergoing unilateral modified Lapidus arthrodesis from January 1, 2007 to December 31, 2008 at participating centers were retrospectively evaluated. The included patients were categorized into early weightbearing (≤ 21 days) and delayed weightbearing (> 21 days) groups. A total of 24 nonunions (6.5%) were identified, with 13 (7.1%) in the early weightbearing group and 11 (6.0%) in the delayed weightbearing group. To date, the present study is the largest multicenter investigation to evaluate early weightbearing after modified Lapidus arthrodesis and the only large study to directly compare early and delayed weightbearing. The findings of the present study have shown that early weightbearing for modified Lapidus arthrodesis does not increase the risk of nonunion when evaluating various fixation constructs.

Early results with use of the midfoot fusion bolt in Charcot arthropathy.

Charcot neuroarthropathy is a complicated condition affecting up to 1 in 680 diabetic patients that can rapidly cause severe destruction of the bony architecture in the foot, with resultant gross instability and frank deformity. Conservative care is not always successful at maintaining an intact soft tissue envelope of the foot; therefore, surgical reconstruction is often attempted in an effort to salvage the limb. The goal is to create a stable, plantigrade foot that can be placed in a shoe or simple brace. However, this effort is dramatically more challenging because of the pathologic bone biology, the inelasticity of the connective tissues, and the difficulty in maintaining non-weightbearing status during the postoperative period. Various forms of internal and external fixation have been described in published studies for use in this setting, all of which have been accompanied by complications such as nonunion, dehiscence, and implant failure. Although the concept of beaming the longitudinal columns of the foot is not new, it has previously been described with the use of cannulated screws. Cannulated screws are inherently weaker than solid-core screws and thus subject to failure at lesser loads. The midfoot fusion bolt offers a technical advantage compared with other forms of fixation in these challenging cases. We present our limited experience with 4 patients who had this device used as a part of the surgical approach and the short-term results. All patients went on to successful union of all fusion sites and were able to return to ambulation in diabetic shoe gear and appropriate bracing.

Arthroscopy for Traumatic Ankle Injuries.

Using ankle arthroscopy in conjunction to open reduction internal fixation of traumatic ankle injuries can play an important role in the management of these injuries by way of treating intra-articular pathologies, leading to improved patient outcomes. While a majority of these injuries are not treated with concurrent arthroscopy, its addition may lead to more prognostic information to dictate the patient's course. This article has illustrated its use in managing malleolar fractures, syndesmotic injuries, pilon fractures and pediatric ankle fractures. While additional studies may be needed to further support AORIF, it may prove to play a vital role in the future.

Isolated medial incisional approach to subtalar and talonavicular arthrodesis.

Triple arthrodesis is commonly used to correct complex deformity with hindfoot valgus. The authors use an isolated medial incisional approach for subtalar and talonavicular joint arthrodesis to correct hindfoot deformity, including high degrees of hindfoot valgus. To assess outcomes achieved with this approach, we reviewed the records of 45 patients from the practices of 5 surgeons. Independent variables evaluated included patient age, primary pathology, use of biologic agents, operative time, time to union, and complications. The median patient age was 57 years (range, 14-78 years). Pathology leading to fusion included 27 (60%) posterior tibial tendon dysfunction, 6 (13.3%) tarsal coalition, 7 (5.5%) degenerative joint disease, 2 (4.4%) rheumatoid arthritis, and 1 (2.2%) each, with Charcot neuroarthropathy, multiple sclerosis, and poliomyelitis. Orthobiological materials were used in 27 (60.0%) of the patients. The median duration of surgery was 87 minutes (range, 65-164 minutes), and the median time to successful arthrodesis was 8 weeks (range, 6-20 weeks). A complication was observed in 6 (13.3%) of the patients, including 1 each of the following: painful calcaneal-cuboid joint, talar fracture, incision dehiscence, poor exposure that required abandonment of the procedure, elevated first ray, and painful fixation. None of the patients experienced a nonunion or an adverse event related to the medial neurovascular structures. Based on our experience with the procedure, the single medial-incision subtalar and talonavicular joint arthrodesis is a useful alternative to triple arthrodesis for the correction of hindfoot valgus deformity.

Sinus Tarsi Approach with Subcutaneously Delivered Plate Fixation for Displaced Intra-Articular Calcaneal Fractures.

Displaced intra-articular calcaneal fractures can be treated with open reduction and internal fixation through various methods, including the extensile lateral approach, sinus tarsi approach, percutaneous reduction and fixation, external fixation, and calcaneoplasty. Although the gold standard is the extensile lateral approach, this method has significant wound-healing complications associated with it. Literature shows that the reduction achieved through minimally invasive techniques is equal to that achieved with the extensile lateral approach, while reducing the amount of postoperative complications. This article outlines a technique that uses the sinus tarsi approach with subcutaneous plate fixation.

Isolated talonavicular arthrodesis for adult onset flatfoot deformity/posterior tibial tendon dysfunction.

Surgical treatment of the adult onset flatfoot deformity can be a vexing problem. This article attempts to define the specific patient population that may benefit from isolated talonavicular arthrodesis. The authors provide an overview of critical biomechanical and anatomic considerations that must be implemented when performing this procedure. The authors also provide a detailed description of surgical technique for isolated talonavicular arthrodesis.

Bioengineered alternative tissues and hyperbaric oxygen in lower extremity wound healing.

With the advent and clinical application of recombinant chemical and cellular mediators of wound healing and a better understanding of the importance of serial debridement, most foot wounds can be healed with little morbidity. Despite these advances, there remains the recalcitrant wound for which more heroic efforts seem warranted. For these patients, advanced wound healing technologies, orthobiologics, and bioengineered alternative tissues may tilt the scales in the direction of definitive wound closure.

Orthobiologics: a survey of materials and techniques.

The modern study of the regenerative capabilities of skeletal tissues began in 1964, when Marshall Urist discovered that bone devoid of inorganic content and dried into a powder could be implanted into the muscle of a rabbit with resultant ectopic bone formation. Use of this technology is now commonplace, and a plethora of orthobiologic materials are available to the foot and ankle surgeon. The science has even become advanced to the point that custom bone replacements can be fabricated in vitro. This points toward an exciting future for the use of this technology by foot and ankle surgeons.

Revision arthrodesis of the foot and ankle.

Previously failed procedures with less than optimal outcomes always are distressing to the patient and surgeon. The revisional arthrodesis may require a higher level of surgical technique and skill than the original procedure from which it was derived. Another level of difficulty is added when the original procedure was deemed to have failed secondary to poor patient compliance. The basic tenets of successful revisional arthrodesis include a motivated and educated patient, adherence to basic surgical principles and techniques, and the ability to extrapolate those principles and techniques into ideas that are born from thinking along the lines of necessity.

Adult flatfoot/posterior tibial tendon dysfunction: classification and treatment.

The authors provide a comprehensive classification and treatment algorithm for the adult flatfoot/posterior tibial tendon dysfunction. As well, the article provides a discussion as to the etiology, biomechanical implications, conservative treatment and surgical pearls of posterior tibial tendon dysfunction.

Soft tissue pathology of the ankle.

Derangements of the soft tissues within the ankle joint are associated with a wide variety of pathophysiology, and typically can be classified as secondary to traumatic injury, rheumatic disease, or congenital lesions. Patients often present with persistent pain, swelling, and limitations on function, usually focused on the anterior aspect of the joint. Evaluation should be guided by a detailed history and physical examination, followed by clinical, laboratory, and imaging studies as indicated. The pathophysiology, diagnosis, and management of these conditions will be the focus of this article.

Revision surgery of the first ray.

When dealing with the first ray, and in particular when preparing for hallux abductovalgus surgery, numerous guidelines are available to help decide what procedure is most appropriate for the pathology based on radiographic findings. However, these guidelines are not as black and white as some physicians may think. Numerous factors affect the selection of a procedure, including physician preference, physician comfort with a procedure, experience with a procedure, and surgical skills. This article takes a clinical look at a number of complications related to surgery and trauma of the first ray, and presents a critical discussion of the thought process used to address the complication.

Midfoot arthrodesis using a locking anterior cervical plate as adjunctive fixation: early experience with a new implant.

A retrospective review was performed on 14 patients (20 arthrodeses) who had undergone midfoot arthrodesis with a semi-constrained, locking anterior cervical plate as a form of adjunctive fixation. Fusion sites where the plate was used for the purpose of arthrodesis included the talonavicular joint, medial naviculocuneiform joints, first metatarsal cuneiform joint, and the calcaneal cuboid joint. All arthrodesis sites used one other type of fixation for the purpose of axial compression. Twenty midfoot arthrodesis sites went on to radiographic union at a mean of 9.1+/-1.5 weeks. A single complication of hardware irritation occurred in one patient that resolved after plate removal. This semi-constrained, locking anterior cervical plate appears to be a viable adjunct to fixation constructs for the purpose of midfoot arthrodesis.