Soft Tissue Structures at Risk With a Percutaneous Focal Dome Osteotomy: A Cadaver Study.

The focal dome osteotomy allows deformity correction through frontal plane rotation, and if needed, anterior or posterior translation. This percutaneous technique allows extracapsular ankle realignment with minimal soft tissue dissection. While circumventing a standard anterior incision, this technique encounters soft tissue structures that must be considered. Focal dome osteotomies were simulated on 10 fresh-frozen below the knee cadavers. Centered proximal to the tibial plafond at the physeal scar, a radial arm using a 4-hole Rancho cube was used to map the dome. Medial, lateral, and central incisions were made to allow access for drilling and measured to nearby anatomic structures. Among 10 cadavers, the age and weight were 70 ± 7.96 years and 134.7 ± 30.8 pounds, respectively. In all cadavers, the hole below the most proximal posthole provided the ideal position for the creation of the osteotomy. The medial and central incisions were closest to the tibialis anterior tendon measuring 3.37 ± 2.48 mm and 0.43 ± 0.9 mm, respectively. The lateral incision and half-pin used to create the distal axis of rotation were closest to the extensor hallucis longus tendon, measuring 1.97 ± 1.92 mm and 1.27 ± 1.5 mm, respectively. Drilling the second hole from the top on a 4-hole Rancho cube, forming a 2.50 cm radial arm, created the ideal osteotomy arc. Though neurovascular structures were further away from respective incision and half-pin sites compared to tendons, in several specimens, anatomic variations held them closer, warranting preoperative handheld Doppler and mapping. Care should be taken to protect anterior ankle anatomy during dissection, drilling, and completing the osteotomy.

Defining the Structures at Risk and an Anatomical Safe Zone for Percutaneous Antegrade Subtalar Joint Fixation With a Single Screw: A Cadaveric Study.

Percutaneous antegrade (anterior to posterior) fixation for subtalar joint (STJ) arthrodesis offers various intraoperative and biomechanical advantages. Currently, the entry point for percutaneous antegrade STJ screw fixation is not clearly described and variable. To our knowledge, there are no publications that evaluate anatomic structures at risk or define an anatomically safe entry point for this fixation. The aim of this investigation was to define an anatomically safe and reproducible entry point for percutaneous antegrade STJ arthrodesis fixation, while also describing anatomic structures at risk when undertaking this method of fixation. We hypothesized that percutaneous single screw antegrade STJ fixation would encroach upon named anatomic structures in more than one cadaveric specimen. Ten cadaver limbs were used in this investigation. A percutaneous guidewire was inserted 5 mm lateral to the tibialis anterior tendon. The midpoint of the talar neck served as the sagittal plane starting point, as seen on the lateral fluoroscopic view. A cannulated 6.5-mm headed screw was inserted antegrade through the STJ into the calcaneus. Each specimen was dissected to assess the distance from the screw to nearby anatomic structures and distance from the tibialis anterior tendon to named structures. Our hypothesis was found to be incorrect, as 0/10 screws invaded neurovascular or tendinous structures. The dorsalis pedis artery and deep peroneal nerve were on average 12.1 ± 2.79 mm and 12.2 ± 2.82 mm lateral to the screw, respectively. These findings are clinically relevant and ultimately allow us to define an anatomic safe starting point for percutaneous antegrade STJ single screw fixation.

Comparing Clinical Characteristics and Short-Term Outcomes Between Adult and Geriatric Patients Undergoing Charcot Reconstruction.

Maintaining an acceptable quality of life following a lifetime of chronic diseases and resulting physiologic effects poses a challenge when treating an aging population. In those with Charcot neuroarthropathy, wounds, and infection complicate decision making when considering limb preservation versus amputation. The purpose of this investigation is to describe the clinical characteristics and short-term outcomes of geriatric patients undergoing Charcot reconstruction. A retrospective chart review of patients who underwent Charcot reconstruction from 2016 to 2022 was conducted. Demographics, medical history, deformity type, surgical intervention, discharge planning, and short-term complications were collected. Descriptive statistics were calculated, and clinical characteristics and short-term outcomes were compared between the non-geriatric, adult (A) and geriatric (G) cohorts using Student's t-test or chi-squared test. Overall, 125 patients were reviewed for final analysis. Charcot deformity type, prevalence of wounds, osteomyelitis, and fixation construct did not significantly differ between groups. While the proportion of those experiencing a prolonged admission did not significantly differ between cohorts, the geriatric group showed age-related pathology including delirium and urinary tract infections. While discharge to nursing facilities did differ between groups (G 43% versus A 19%), baseline function did not. The 30-day unplanned readmission and mortality rates did differ between groups, though this difference was not statistically significant. Prior to geriatric Charcot reconstruction, consideration should be given to age-related comorbidities. Specifically, with a greater incidence of age-related complications unrelated to the surgery as well as mortality in the geriatric group, complications should be discussed at length.

Anatomic Description of the Calcaneocuboid Joint: Implications for Staple Fixation.

Understanding the anatomy of the calcaneocuboid (CCJ) remains essential when selecting staple fixation to optimize osseous purchase during rearfoot procedures. This anatomic study quantitatively describes the CCJ in relation to staple fixation sites. The calcaneus and cuboid from 10 cadavers were dissected. Widths at 5 mm and 10 mm increments away from the joint were measured in dorsal, midline, and plantar thirds of each bone. The widths between each position's 5 mm and 10 mm increments were compared using the Student's t test. The widths among the positions at both distances were compared using an ANOVA then post hoc testing. Statistical significance was set at p ≤ 0.05. The middle (23 ± 3 mm) and plantar third (18 ± 3 mm) of the calcaneus at the 10 mm interval was greater than the 5 mm interval (p = .04). At 5 mm distal to the CCJ, the dorsal third of the cuboid maintained a statistically significant greater width than the plantar third (p = .02). The 5 mm (p = .001) and 10 mm (p = .005) dorsal calcaneus widths as well as the 5 mm (p = .003) and 10 mm (p = .007) middle calcaneus widths were significantly greater than the plantar widths. This investigation supports the use of 20 mm staple 10 mm away from the CCJ in dorsal and midline orientations. Care should be taken when placing a plantar staple within 10 mm proximal to the CCJ as the legs may extend beyond the medial cortex compared to dorsal and midline placements.

Readability, Understandability, and Actionability of Online Limb Preservation Patient Education Materials.

With countless sites detailing disease management, treatment, and prognosis, patients often turn to the internet for medical decision-making assistance. While such sites provide ample patient education material, little is known about the reading level, understandability, and actionability of information on these sites. In a limb preservation population, assessing what information patients are interpreting becomes vital to ensure care is not compromised. Internet searches of the terms "Charcot foot, diabetic foot ulcer, foot ulcer, critical limb ischemia, gangrene, osteomyelitis, lymphedema, DVT, pulmonary thrombosis, and amputation" were performed. The Flesch Kincaid readability score from the text from the first 10 links with patient education information were calculated. Understandability and actionability of each resource were then graded by 2 reviewers. Across the 100 accessed websites, 10% maintained patient education materials with at least one readability score at or below the recommended sixth grade reading level. Seventy-three percent of the materials revealed an understanding greater than the recommended 70%. Ninety-nine percent of materials maintained patient education materials with actionability less than 70%. The Spearman Rho correlation revealed a statistically significant relationship between understandability score and the order of each keyword's respective website search position (Rho = -0.01; p = .002). Overall, many online limb preservation patient education materials are written well above the recommended sixth grade reading level with varying understandability and actionability scores. Online resources, as well as physician offices, should examine their patient education materials to ensure they are of an appropriate reading level and provide actions to be taken in case of emergencies.

Correlation of Lisfranc Injuries With Regional Bone Density.

Lisfranc injuries present a challenge due to their ubiquity though frequent missed diagnoses. A paucity of data exists associating the contribution of bone density to injury type. This investigation compares the regional bone density between Lisfranc injury types using computed-tomography (CT)-derived Hounsfield units. A retrospective chart review identified patients with gross ligamentous and avulsion-type Lisfranc injuries determined by CT examination of the second metatarsal base and medial cuneiform. Regional bone density was assessed by averaging the Hounsfield units of the first metatarsal base, navicular, cuboid, calcaneus, and talus between 2 reviewers. Density was compared between injury type, isolated concomitant forefoot, and mid/hindfoot fractures. One hundred thirty-four patients were separated into avulsion (n = 85) and ligamentous (n = 49) groups. No statistically significant difference in patient body mass index, age, smoking status, or Quenu and Kuss injury pattern was observed between groups. The regional bone density of the cuboid (p = .03) and talus (p = .04) was greater in the ligamentous group. Lower extremity concomitant mid/hindfoot fracture patients exhibited greater regional bone density in the ligamentous group in all assessed bones (p ≤ .04) except the calcaneus. Ligamentous injuries of the Lisfranc complex are associated with increased regional bone density among patients sustaining concomitant mid/hindfoot fractures. This study expands the utility of regional bone density analysis in foot and ankle trauma.

CMS Open Payments Database Analysis of Industry Payments for Foot and Ankle Surgery Research.

With decreasing federal funding, the role of industry in supporting medical investigations continues to grow. To increase transparency between physicians and industry, the Centers for Medicare and Medicaid Services introduced the Open Payments Program, providing a searchable database of physician payments from entities including medical device companies. This study describes industry research payments and trends among foot and ankle surgeons. Research Payment Data among foot and ankle surgeons from the Open Payments Database was reviewed from 2013 through 2020. Payment year, value, type, and physician name were collected, and descriptive statistics were presented. Linear regression assessed trends in the number and value of payments. Analysis of variance and subsequent post hoc testing assessed differences in mean payment value. A p value of ≤.05 was considered statistically significant. Overall, 10,872 payments totaling $69,595,393.10 among 446 foot and ankle surgeons were analyzed. No statistically significant increase in number of physicians, payments, or mean payment value per physician was observed from 2013 through 2020. However, the average value of payments in 2019 and 2020 was greater than 2015 and 2017 (p ≤ .05). The top 50 physicians according to cumulative payment value received $54,696,623.10 with 9427 (86.7%) cash and cash-equivalent payments representing the most common payment type overall. Industry continues to provide financial support to foot and ankle surgery research. Results of this investigation spur future studies to examine the relationship between payments and positive results reported by lead investigators in published research.

Self-Reported Conflicts of Interests and Financial Disclosures in The Journal of Foot & Ankle Surgery: A Systematic Review.

Industry, academia, and professional societies provide financial and in-kind support for physician-lead research; however, the prevalence and role remain unreported. From consultancies to leadership positions, foot and ankle surgeons receive a spectrum of support. To provide transparency between these relationships and published outcomes, journals report conflicts of interest (COI) and financial disclosures (FD). This investigation analyzes self-reported COIs and FDs in The Journal of Foot & Ankle Surgery (JFAS)®. A systematic review of manuscripts reporting COIs and FDs from the January 2008 through November 2020 issues of JFAS was conducted. Editorials, commentaries, and technique articles were excluded. Disclosure type, level of evidence, and affiliated country of authorship were collected. Trends and proportions of articles with disclosures were analyzed from before a published Open Payments Database (OPD) (2008-2013) through 2020. Among 2699 articles, 382 reported a COI or FD. The number of manuscripts with COIs and FDs increased since 2008 (p < .001). The proportion of articles with COIs or FDs was greater after the OPD was published compared to prior (p < .001). Overall, 86.35% of reported COIs were industry related while 37.09% of FDs were hospital, university, or state sponsor affiliated. International authorship was a negative predictor of COIs and FDs (p < .001). Level 3 and 4 studies were 4.60 (95%CI [0.85-24.85]) and 5.56 (95%CI [1.04-29.72]) times as likely to have self-reported a COI compared to level 1 studies, respectively. Level 2 and 5 studies were 0.33 (95%CI [0.04-3.16]) and 0.36 (95%CI [0.04-3.13]) times as likely to have self-reported a FD compared to level 1 studies, respectively. This investigation found an increase in the proportion of manuscripts with self-reported COIs and FDs since first documented in JFAS. These findings illustrate the ubiquity of author industry involvement, though future studies may examine the relevancy of these roles to published research.

Surgical considerations for the neglected or chronic Achilles tendon rupture: a combined technique for reconstruction.

The Achilles tendon is among the most commonly injured tendons in the human body. The most common reason for delayed treatment is a missed diagnosis or a deficiency in presentation. The neglected or chronically ruptured Achilles tendon presents a unique treatment challenge. The surgical approach varies greatly depending on the extent of degeneration and the resultant gap between the opposing tendon ends. Most surgeons have recommended the use of a tendon transfer or augmentation to strengthen the Achilles tendon repair. The following technique uses a flexor hallucis longus tendon transfer with gastrocnemius aponeurosis turndown flap augmentation. This technique has been commonly performed by us with success.

The Aggressive Open Anterior Ankle Cheilectomy as Joint Salvage for Anterior Ankle Impingement Syndrome and Arthritis.

Anterior ankle impingement syndrome can frequently present in athletes and post-traumatic patients who have osteophytes contributing to limited dorsiflexion and pain. Surgical treatment options include arthroscopy, open arthrotomy, arthrodesis, and total implant arthroplasty. For many, joint-sparing arthroscopy or arthrotomy yield satisfactory results if significant debridement is performed. If debridement is not aggressive, patients may not obtain the desired improvement. In cases where a larger amount of bone must be removed, or the patient does not have an anatomic appearing talar neck due to osteophytic changes, we have found that an open approach is necessary to achieve good results. To the best of our knowledge, no such technique has been previously published detailing a standard approach to open ankle arthrotomy. Our technique is coined the "Aggressive Open Anterior Ankle Cheilectomy" and involves a systematic 3-step approach. First, the tibial osteophytes are resected with an osteotome; second, the ankle gutters are addressed, and all hypertrophic bones removed; and third, an anatomic talar neck is fashioned. We herein describe our surgical technique and case examples.Level of Evidence: 5.

Parallax and Distortion in Fluoroscopy Units.

BACKGROUND: Parallax is an imaging phenomenon where an object appears to be at different positions when viewed from different angles. Distortion can occur secondary to internal fluoroscopic, or external environmental, factors. Fluoroscopy is a vital tool to assist surgeons intraoperatively. However, parallax and distortion can lead to inaccuracy, potentially leading to incorrect surgical decisions. The purpose of this study was to investigate the prevalence of parallax/distortion in large fluoroscopy units at a level-1 trauma center. METHODS: Two types of C-arm models were evaluated, including (1) round image intensifiers, and (2) flat plate detectors (FPD). A square plexiglass grid with embedded wire at ½-in intervals was created, with a round metal washer secured centrally. The grid was placed 16 in from the image intensifier. A metal ball bearing (BB) was secured to the center of the x-ray tube. Fluoroscopic images were obtained until the BB and washer were "center-center." A straight blade served as a fiducial marker to ensure there was no off-axis angulation. Standard anterior-posterior and lateral views were obtained. External factors were considered, tested, and limited. Images were printed and the patterns of parallax/distortion were identified. RESULTS: All 11/11 (100%) of fluoroscopy units had some degree of parallax and/or distortion. We noted 3 different patterns, including sigmoidal, converging, and diverging. The FPD units had less apparent distortion overall; however, two-thirds (66%) were off-axis in the x- and y-axes in relation to the fiducial marker. CONCLUSION: All fluoroscopy units had varying degrees and patterns of parallax/distortion. We noted less overall distortion in FPDs. However, some of these units may produce images that are off-axis. This research has important implications for improving the accuracy of intraoperative fluoroscopy. Musculoskeletal surgeons should understand the limitations of fluoroscopy and how to combat parallax distortion to improve surgical outcomes and reduce patient morbidity. LEVEL OF EVIDENCE: Level V.

Role of body mass index in acute charcot neuroarthropathy.

Obesity has been posited as a predictor for the development of Charcot neuroarthropathy, a severe form of degenerative joint disease associated with peripheral neuropathy and diabetes mellitus. The present case-control study investigated the relationship between elevated (overweight and obese) body mass index and acute Charcot neuroarthropathy in a diabetic population. The final data set consisted of 49 patients, 20 (40.82%) of whom had Charcot foot and 29 (59.18%) who served as controls. In the present investigation, no statistically significant association was found between an elevated body mass index and the development of acute Charcot neuroarthropathy involving the foot.

Technical considerations for surgical intervention of Jones fractures.

Jones fractures are a common injury treated by foot and ankle surgeons. Surgical intervention is recommended because of the high rate of delayed union, nonunion, and repeat fracture, when treated conservatively. Percutaneous intramedullary screw fixation is commonly used in the treatment of these fractures. We present techniques that can increase the surgical efficiency and decrease the complications associated with percutaneous delivery of internal fixation.

Surgical approach for combined ankle and subtalar joint chronic mechanical instability.

Combined ankle and subtalar joint instability can lead to severe disability of the lower extremity. Multiple procedures have been described for hindfoot and ankle instability, including anatomic and non-anatomic reconstructions. The authors present their technique consisting of a free autogenous split peroneus longus tendon graft combined with a modified Brostrom-Gould repair.

Factors affecting healing of ankle fractures.

Ankle fractures have been widely described in orthopedic and podiatric studies. These injuries have been associated with significant patient morbidity, infection, malunion, nonunion, and arthritis. Avoiding complications and optimizing outcomes demands an awareness of the factors affecting the healing of ankle fractures. The prognosis of surgical treatment of these injuries has varied according to patient factors or injury severity, or a combination. Cigarette smoking, obesity, and diabetes are some of the factors linked to the prognosis of ankle fractures. We conducted a retrospective cohort study of 58 patients treated for an ankle fracture at a single center. The objective of the present study was to comprehensively evaluate the factors affecting the clinical outcome of surgically treated ankle fractures.

Functional Outcomes and Complications Associated With Total Talus Arthroplasty: A Systematic Review.

Total talus arthroplasty (TTA) is a motion sparing procedure which can be utilized in specific and unique cases of talar necrosis and/or collapse. Literature on TTA is limited and predominantly composed of case studies or case reports. The purpose of this publication is to compile a systematic review of functional outcomes and complications associated with TTA. A search of current literature on TTA with >1-year follow-up was performed. Studies that described talar body implants or talonavicular implants were excluded. Twenty articles met inclusion criteria, which represented 161 TTAs. The average follow-up was 37.35 months (9-60 months). The indication for a TTA was predominately avascular necrosis of the talus, comprising 75.78% (122/161) of cases. The overall complication rate was 9.32% (15/161), with wound healing complications (5/161), replacement or implantation of a tibial component (4/161), and medial malleolus fracture (3/161) being the most common. One patient required proximal amputation due to residual pain and deformity. Functionally, American Orthopedic Foot and Ankle Score increased from 27.93 preoperative to 81.99 postoperative and Japanese Society for Surgery of the Foot Score increased from 43.2 preoperative to 89.34 postoperative. Visual analog scale pain score decreased from 6.44 to 2.60. Total ankle range of motion increased from 36.60° to 46.74°. Ankle plantarflexion increased by 3.45° and ankle dorsiflexion increased by 6.69°. Overall, available literature on TTA appears to be in favor of the procedure when indicated.Levels of Evidence: 4.

An anatomic safe zone for posterior ankle arthroscopy: a cadaver study.

Posterior ankle arthroscopy has traditionally been associated with concern for injury to the posterior tibial nerve and vessels, and this concern is greatest when the patient is positioned supine. Positioning the patient prone could be a safer method for posterior ankle arthroscopy. The purpose of this cadaver study was to determine the anatomic safe zone devoid of vital structures relative to the posteromedial and posterolateral arthroscopic portals created. In addition, exposure of the posterior ankle was evaluated by direct visualization and fluoroscopy to determine the relative utility of these portals. Based on our findings, which are consistent with other previously reported results, we believe that a wide range of ankle pathology can be suited to treatment by means of posterior arthroscopy with the patient in the prone position.

Incidence of talar dome lesions with concomitant peroneal tendon pathologic features: a magnetic resonance imaging evaluation.

Few studies have evaluated the incidence of talar dome lesions and injuries to the peroneal tendons occurring concomitantly. The purpose of our research was to evaluate the incidence of osteochondral lesions of the talus (OLT) with peroneal tendon pathologic features according to the magnetic resonance imaging (MRI) findings. A database search was conducted in the Department of Radiology at the Western Pennsylvania Hospital and Forbes Regional Campus for all MRI examinations ordered by attending physicians of the Department of Foot and Ankle Surgery from 2008 to 2010. A total of 810 MRI reports were reviewed, of which 198 contained a diagnosis of peroneal tendon pathologic features (e.g., tenosynovitis, split tears) or OLT (i.e., chondral, osteochondral, subchondral edema, cystic changes), or both. MRI scans were then reviewed to confirm the report findings and findings not identified in the report. A total of 76 patients were identified as having an OLT. Of these 76 patients, 49 had associated peroneal tendon pathologic features. MRI evaluation revealed that 49 (65.3%) of the 76 patients with a talar dome lesion had concomitant peroneal pathologic features. Talar dome lesions with concomitant tears/tendinopathy of the peroneus brevis were associated in 14.6%. The incidence of an OLT with tears/tenosynovitis of the peroneus longus was 10.6%, because tears/tendinopathy of both peroneal tendons was present in 18.6%. Tenosynovitis of the brevis and longus were seen in 21.3% of those with an OLT. Our findings suggest the need for an increased level of suspicion for injuries to the lateral ankle ligaments, peroneal tendon complex, and ankle joint when evaluating a patient with ankle instability and chronic pain.

A Novel Insertional Achilles Tendon Rupture Repair After Heel Spur Debridement: A Case Report.

CASE: We report a case of a 46-year-old woman who suffered an insertional Achilles tendon rupture secondary to a fall after undergoing retrocalcaneal and Achilles tendon debridements with flexor tendon transfer. Examination revealed posterior ankle pain with insertional Achilles tendon retraction. Treatment options included continued immobilization vs. surgical repair. She underwent Achilles tendon tenodesis to the calcaneus using a combined gastrocsoleus recession and Krackow suture technique. CONCLUSION: At the 1-year follow-up, examination revealed pain-free return to normal function. In the presence of a ruptured Achilles tendon with retraction, this repair provided sufficient lengthening and fixation of the Achilles tendon complex.

The hematoma block: a simple, effective technique for closed reduction of ankle fracture dislocations.

Management of a dislocated ankle fracture can be challenging because of instability of the ankle mortise, a compromised soft tissue envelope, and the potential neurovascular compromise. Every effort should be made to quickly and efficiently relocate the disrupted ankle joint. Within the emergency department setting, narcotics and benzodiazepines can be used to sedate the patient before attempting closed reduction. The combination of narcotics and benzodiazepines provides relief of pain and muscle guarding; however, it conveys a risk of seizure as well as respiratory arrest. An alternative to conscious sedation is the hematoma block, or an intra-articular local anesthetic injection in the ankle joint and the associated fracture hematoma. The hematoma block offers a comparable amount of analgesia to conscious sedation without the additional cardiovascular risk, hospital cost, and procedure time.