A Patient-Reported Outcome-Based Comparison of Cheilectomy With and Without Proximal Phalangeal Dorsiflexion Osteotomy for Hallux Rigidus.

INTRODUCTION: This study provides the first comparison of patient-reported outcomes between isolated cheilectomy (C) and cheilectomy with Moberg (CM) osteotomy for hallux rigidus. METHODS: A single-center, retrospective registry search identified all patients with preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores who underwent cheilectomy, with and without concomitant proximal phalangeal dorsiflexion osteotomy, for hallux rigidus between January 2016 and December 2020. Because there were far fewer isolated cheilectomies (62), all C patients were compared with a commensurate number of consecutive CM cases (67) using preoperative, 1-year, and 2-year PROMIS scores for physical function, pain interference, pain intensity, global physical health, global mental health, and depression, as well as complication and revision data from a chart review. A multivariable linear regression analysis was performed to compare adjusted postoperative PROMIS scores between the 2 cohorts. RESULTS: There were no differences between groups among the demographic and preoperative variables compared. The CM cohort reported worse pain interference scores preoperatively (P < .001) and at 1 year postoperatively (P = .01). However, the C cohort reported worse pain intensity scores preoperatively (P < .001) and at 1 year postoperatively (P < .001). Adjusted postoperative PROMIS score comparison demonstrated that the CM cohort had better 1-year postoperative pain intensity scores (P < .05). However, there were no differences between cohorts for additional PROMIS scores or complications data. CONCLUSION: The addition of a Moberg osteotomy does not appear to significantly change short- to medium-term outcomes of cheilectomy for hallux rigidus treatment. LEVELS OF EVIDENCE: Level III: Retrospective comparative study.

Orthotic Devices for the Foot and Ankle.

Millions of Americans wear ankle-foot orthotic devices for protection, pain relief, and deformity correction. Inquiries about off-the-shelf and custom devices are a common reason for evaluation with a foot and ankle surgeon or general orthopaedic surgeon. Despite limited high-quality evidence for their use, these devices can have a notable clinical impact on physical function. An up-to-date understanding of orthotic device options and their appropriate use in managing musculoskeletal pathologies applies to all orthopaedic providers. This review aims to categorize orthosis types and provide specific device recommendations for common adult conditions such as flatfoot, cavovarus foot, and ankle instability. Collaboration with a certified orthotist can help patients achieve functional and recreational goals with the use of appropriately designed and applied orthoses.

Clinical Outcomes and Rotational Correction of First Metatarso-Cuneiform Fusion With First Metatarsal to Second Cuneiform Fixation.

Background: The modified Lapidus procedure (first metatarso-cuneiform fusion) is a powerful technique for correcting triplanar deformity in hallux valgus. Although traditionally fixed with cross-screws (CS), growing awareness of intercuneiform stability and pronation deformity has led to fixation using a plate and first metatarsal-second cuneiform (1MT-2C) screw fixation (PS). We investigated Lapidus patient cohorts using CS vs PS fixation to understand patient-reported outcomes, angular and rotational correction, and complication rates. Methods: We retrospectively reviewed cases of modified Lapidus for hallux valgus by a single surgeon. Patients were divided into CS or PS groups according to fixation. All patients had preoperative Patient Reported Outcome Measurement Information System (PROMIS) scores and minimum 12 months of follow-up. PROMIS scores in 6 key domains were compared within and between groups. Radiographic assessment of hallux valgus angle and intermetatarsal angle were performed on pre- and postoperative XR. Pronation of the first ray was measured on pre- and postoperative weightbearing computed tomography. Results: We compared 42 patients with PS fixation to 43 with CS fixation. Both groups had significant improvement in hallux valgus angle and intermetatarsal angle (P < .001), with no difference between groups. PS patients experienced a greater correction of first metatarsal pronation, an average reduction of 11 degrees, compared to 8 degrees in the CS group (P < .039). Both cohorts experienced improvement in PROMIS physical function, pain interference, pain intensity, and global physical function. There were no differences in PROMIS score improvements between the cohorts. The CS group started weightbearing at 6 weeks vs 3.6 weeks for the PS group. Complication and revision rates were similar. Conclusion: A plate and 1MT-2C screw fixation provides safe, robust fixation of Lapidus procedure and prevents instability through the intercuneiform joint. We observed similar improvement in PROMIS compared with patients treated with cross-screws. Complications did not increase despite the PS group weightbearing much earlier. PS patients achieved greater first ray rotational correction. Level of Evidence: Level III, retrospective cohort study.

Effect of Prior Cheilectomy on Outcomes of First Metatarsophalangeal Joint Fusion for Treatment of Hallux Rigidus.

Background: Patients with hallux rigidus who do not experience significant pain relief after cheilectomy often require a conversion to metatarsophalangeal (MTP) fusion. However, it is unclear whether the previous cheilectomy affects outcomes of the subsequent fusion. The aim of this study was to compare patient-reported outcomes and complications in patients undergoing MTP fusion for hallux rigidus between patients with a history of cheilectomy and those undergoing a fusion as a primary procedure. Methods: This retrospective cohort study included patients who underwent MTP fusion who had preoperative and minimum 1-year postoperative Patient Reported Outcomes Measurement Information System (PROMIS) scores. Patients were divided into a "primary MTP fusion" cohort and a "prior cheilectomy" cohort based on their history of a previous cheilectomy. Preoperative, postoperative, and improvement in PROMIS scores, along with rates of complications including nonunion, infection, interphalangeal (IP) joint pain, and removal of hardware were compared between groups. Results: The prior cheilectomy group had significantly lower preoperative physical function scores than the primary MTP fusion group (P < .05). Postoperatively, the prior cheilectomy group had worse physical function (P < .017) and global physical health (P < .017) scores. However, there were no significant differences in pre- to postoperative change in PROMIS scores. There were no significant differences in rates of nonunion (P = .99), infection (P = .99), or hardware removal (P = .99). More patients in the prior cheilectomy group had IP joint pain (P = .034). Conclusion: This study found that a prior cheilectomy may not affect serious complication rates of a subsequent fusion, but it may be associated with worse baseline function. Overall, our results suggest that a prior failed cheilectomy does not influence the amount of improvement in function and pain from MTP fusion. Level of Evidence: Level III, retrospective cohort study.

Treatment of Thumb Metacarpophalangeal Joint Hyperextension by Volar Plate Advancement and Capsulodesis With Suture Tape Augmentation.

Basal joint arthritis is commonly associated with attenuation of the volar structures at the thumb metacarpophalangeal (MCP) joint, leading to an initially dynamic, and eventually passive hyperextension deformity. In surgical treatment of basilar thumb disease, intervention at the MCP joint should also be considered to correct deformity and prevent persistent dysfunction. We present a novel technique using suture tape augmentation of the thumb MCP joint volar plate advancement and capsulodesis, with the goal of preventing recurrent instability as a result of tissue attenuation and enabling early functional recovery. We also report a representative case of a 66-year-old woman with symptomatic thumb carpometacarpal osteoarthritis and 50 degrees of MCP passive hyperextension. She underwent trapeziectomy and MCP joint volar plate advancement and capsulodesis with suture tape augmentation. Postoperatively, the patient underwent early mobilization of the affected thumb and at final follow-up of 2 years postsurgery had a painless thumb with full opposition and without hyperextension at the MCP joint during pinch maneuvers.

Assessment of Flatfoot Deformity Using Digitally Reconstructed Radiographs: Reliability and Comparison to Conventional Radiographs.

BACKGROUND: Digitally reconstructed radiographs (DRRs) generated from weightbearing computed tomography (WBCT) may potentially substitute for weightbearing plain radiographs (XRs) but have not been clinically validated. This study aims to test the reliability of 6 radiographic parameters of progressive collapsing foot deformity (PCFD) as measured on DRR, to investigate whether DRR represents comparably to XR through the same measurements, and to compare agreement of DRR and XR measurements of a standardized arch height parameter with reference measurements made on WBCT. METHODS: DRR generated from preoperative WBCT of 71 patients (72 feet) treated surgically for PCFD were retrospectively compared with preoperative weight-bearing XR after exclusion criteria were applied. Six radiographic measurements were performed, including Meary angle, calcaneal pitch (CPA), medial cuneiform height (MCH), AP talar-first metatarsal angle (T-1MT), talonavicular coverage (TNCA), and talar incongruency (TIA). Arch height was measured on XR, DRR, and WBCT using a validated, standardized, navicular-based index. Intraclass correlation coefficients assessed DRR intraobserver and interobserver reliability. Paired samples t tests tested differences between XR and DRR. Bland-Altman limits of agreement analysis compared DRR and XR agreement with WBCT measurements. RESULTS: Measurements were within standard PCFD ranges on XR and DRR. All measurements demonstrated excellent intrarater reliability and good to excellent interrater agreement, consistent with previous literature on XR. No differences were found for Meary, CPA, or TNCA. Minor differences were observed for MCH, T-1MT, and TIA. DRR measurements demonstrated greater agreement with WBCT than XR measurements. CONCLUSION: DRR from WBCT may be a promising substitute for XR in the clinical evaluation of PCFD. Radiographic measurements made on DRR demonstrated good to excellent reliability. Although small differences were found between XR and DRR for certain measurements, DRR more accurately represented medial arch anatomy compared to gold standard WBCT data than XR. If validated as a clinical substitute, DRR could eventually obviate XR where WBCT is available. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

The influence of concomitant hammertoe correction on postoperative outcomes in patients undergoing hallux valgus correction.

BACKGROUND: Patients with hallux valgus often develop secondary hammertoe deformities of the lesser toes. Operative management of bunions with hammertoe can be more extensive; however, it is unclear whether this affects patient-reported outcomes. The aim of this study was to compare postoperative patient-reported outcome measures and radiographic outcomes between patients who underwent isolated bunion correction and patients who underwent simultaneous bunion and hammertoe correction. METHODS: Preoperative, postoperative, and change in Patient-Reported Outcomes Measurement Information System (PROMIS) scores were compared between patients who underwent isolated hallux valgus correction and those who underwent concomitant hammertoe correction. Radiographic measures including hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal-articular angle (DMAA), and Meary's angle were also compared. Targeted minimum-loss estimation (TMLE) was used for statistical analysis to control for confounders. RESULTS: A total of 221 feet (134 isolated bunion correction, 87 concomitant hammertoe correction) with a minimum of 12 months follow-up were included in this study. Both cohorts demonstrated significant improvements in the physical function, pain interference, pain intensity, and global physical health PROMIS domains (all p < 0.001). However, patients in the concomitant hammertoe cohort had significantly less improvements in pain interference and pain intensity (p < 0.01, p < 0.05 respectively). The concomitant hammertoe cohort also had significantly higher postoperative pain interference scores than the isolated bunion cohort (p < 0.01). Radiographic outcomes did not differ between the two groups. CONCLUSION: While both isolated bunion correction and concomitant hammertoe correction yielded clinically significant improvements in patient reported outcomes and normalized radiographic parameters, patients undergoing simultaneous bunion and hammertoe correction experienced substantially less improvement in postoperative pain-related outcomes than those who underwent isolated bunion correction.

Cavovarus With a Twist: Midfoot Coronal and Axial Plane Rotational Deformity in Charcot-Marie-Tooth Disease.

BACKGROUND: The cavovarus deformity of Charcot-Marie-Tooth (CMT) disease is often characterized by a paradoxical relationship of hindfoot varus and forefoot valgus. The configuration of the midfoot, which links these deformities, is poorly understood. Accurate assessment of 3-dimensional alignment under physiologic loadbearing conditions is possible using weightbearing computed tomography (WBCT). This is the first study to examine the rotational deformity in the midfoot of CMT patients and, thus, provide key insights to successful correction of CMT cavovarus foot. METHODS: A total of 27 WBCT scans from 21 CMT patients were compared to control WBCTs from 20 healthy unmatched adults. CMT patients with a history of bony surgery, severe degenerative joint disease, or open physes in the foot were excluded. Scans were analyzed using 3-dimensional software. Anatomic alignment of the tarsal bones was calculated relative to the anterior-posterior axis of the tibial plafond in the axial plane, and weightbearing surface in the coronal plane. RESULTS: Maximal rotational deformity in CMT patients occurred at the transverse tarsal joints, averaging 61 degrees of external rotation (supination), compared to 34 degrees among controls (P < .01). The talonavicular joint was also the site of peak adduction deformity in the midfoot, with an average talonavicular coverage angle measuring 12 degrees compared with -11 degrees in controls (P < .01). CONCLUSION: This 3-dimensional WBCT analysis is the first to isolate and quantify the multiplanar rotational deformity in the midfoot of CMT patients. Compared with healthy unmatched control cases, CMT patients demonstrated increased axial plane adduction and coronal plane rotation at the talonavicular (TN) joint. These findings support performing soft tissue release at the TN joint to abduct and derotate the midfoot as a first step for targeted deformity correction. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

Safety and Efficacy of Postoperative Indwelling Popliteal Nerve Catheters for Outpatient Charcot-Marie-Tooth Surgery.

BACKGROUND: Outpatient surgical deformity correction for Charcot-Marie-Tooth (CMT) disease is limited by effective postoperative pain control. Our previous institutional protocol for foot and ankle surgery in this population included preoperative single-injection nerve blocks, but patients often experienced uncontrolled pain when the block wore off postoperative day 0 or 1, resulting in high opioid requirements and unplanned emergency department visits. The use of ultrasonography-guided continuous nerve catheters in CMT patients has not previously been studied. We aimed to prospectively investigate the safety and efficacy of ultrasonography-guided indwelling popliteal catheters in CMT patients undergoing outpatient foot deformity correction surgery. METHODS: Twenty CMT patients, average 28 (range 13-53) years old, undergoing reconstructive surgery by a single foot and ankle attending surgeon were consented for preoperative ultrasonography-guided popliteal catheters. This series included 24 total outpatient procedures; 4 were staged bilateral. Indwelling popliteal catheters were maintained on discharge, providing continuous infusion until postoperative day (POD) 3, and then self-discontinued. Patients were prescribed oxycodone 5 mg (60-80 pills) as needed for breakthrough pain. Outcomes collected included daily pain scores (0-10), an opioid pill count on POD 14, and patient satisfaction ratings. Neurologic evaluation by 5-point 10g Semmes-Weinstein monofilament testing was performed preoperatively and on POD 14. RESULTS: There were no observed catheter-site infections or hematomas. Nine of the patients had pre-existing sensory deficits involving at least 2 areas on the 5-point monofilament test. Postoperative testing showed these deficits were unchanged and there were no instances of new sensory deficits. Postoperative pain scores were typically low, with median values (interquartile ranges [IQRs]) of 3.5 (2.0-5.0) on POD 1, 2.5 (2.0-5.0) on POD 2, and 2.5 (1.0-3.75) on POD 3. At POD 14, pain was 1.0 (0-1.0). Patients consumed a median of 25 oxycodone pills (IQR 8-43) over 2 weeks, less than half the prescribed number. Patient satisfaction was high. All patients reported they would choose to have a nerve catheter again for a similar surgery. CONCLUSION: This cases series demonstrated that regional anesthesia using ultrasonography-guided indwelling popliteal catheters was safe and effective for pain control in CMT patients undergoing outpatient foot and ankle surgery. Opioid consumption was comparable to published rates following major bony procedures, and no patients required emergent treatment or hospital admission for uncontrolled pain. No new sensory deficits were detected and patients with underlying sensory deficits remained unchanged. Patients were highly satisfied. LEVEL OF EVIDENCE: Level IV, case series.

Abnormal Bone Morphology in Charcot-Marie-Tooth Disease.

BACKGROUND: Although long suspected, it has yet to be shown whether the foot and ankle deformities of Charcot-Marie-Tooth disease (CMT) are generally associated with abnormalities in osseous shape. Computed tomography (CT) was used to quantify morphologic differences of the calcaneus, talus, and navicular in CMT compared with healthy controls. METHODS: Weightbearing CT scans of 21 patients (27 feet) with CMT were compared to those of 20 healthy controls. Calcaneal measurements included radius of curvature, sagittal posterior tuberosity-posterior facet angle, and tuberosity coronal rotation. Talar measurements included axial and sagittal body-neck declination angle, and coronal talar head rotation. Surface-mesh model analysis of the hindfoot was performed comparing the average of the CMT cohort to the controls using a CT analysis software (Disior Bonelogic 2.0). Means were compared with a t test (P < .05). RESULTS: CMT patients had significantly less talar sagittal declination vs controls (17.8 vs 25.1 degrees; P < .05). Similarly, CMT patients had less talar head coronal rotation vs controls (30.8 vs 42.5 degrees; P < .001). The calcaneal radius of curvature in CMT patients was significantly smaller than controls (822.8 vs 2143.5 mm; P < .05). CMT sagittal posterior tuberosity-posterior facet angle was also significantly different from that of controls (60.3 vs 67.9 degrees respectively; P < .001).Surface-mesh model analysis demonstrated the largest differences in morphology at the navicular tuberosity, medial talar head, sustentaculum tali, and anterior process of the calcaneus. CONCLUSION: This is the first study to quantify the morphologic differences in hindfoot osteology seen in CMT patients. Patients identified with osseous changes of the calcaneus, especially a smaller axial radius of curvature, may benefit from a 3-dimensional osteotomy for correction.

How Are Orthopaedic Surgery Residencies Responding to the COVID-19 Pandemic? An Assessment of Resident Experiences in Cities of Major Virus Outbreak.

BACKGROUND: In response to COVID-19, American medical centers have enacted elective case restrictions, markedly affecting the training of orthopaedic residents. Residencies must develop new strategies to provide patient care while ensuring the health and continued education of trainees. We aimed to describe the evolving impact of COVID-19 on orthopaedic surgery residents. METHODS: We surveyed five Accreditation Council for Graduate Medical Education-accredited orthopaedic residency programs within cities highly affected by the COVID-19 pandemic about clinical and curricular changes. An online questionnaire surveyed individual resident experiences related to COVID-19. RESULTS: One hundred twenty-one resident survey responses were collected. Sixty-five percent of the respondents have cared for a COVID-19-positive patient. One in three reported being unable to obtain institutionally recommended personal protective equipment during routine clinical work. All programs have discontinued elective orthopaedic cases and restructured resident rotations. Most have shifted schedules to periods of active clinical duty followed by periods of remote work and self-isolation. Didactic education has continued via videoconferencing. DISCUSSION: COVID-19 has caused unprecedented changes to orthopaedic training; however, residents remain on the front lines of inpatient care. Exposures to COVID-19 are prevalent and residents have fallen ill. Programs currently use a variety of strategies to provide essential orthopaedic care. We recommend continued prioritization of resident safety and necessary training accommodations.

A Consensus Statement on the Surgical Treatment of Charcot-Marie-Tooth Disease.

BACKGROUND: Charcot-Marie-Tooth (CMT) disease is a hereditary motor-sensory neuropathy that is often associated with a cavovarus foot deformity. Limited evidence exists for the orthopedic management of these patients. Our goal was to develop consensus guidelines based upon the clinical experiences and practices of an expert group of foot and ankle surgeons. METHODS: Thirteen experienced, board-certified orthopedic foot and ankle surgeons and a neurologist specializing in CMT disease convened at a 1-day meeting. The group discussed clinical and surgical considerations based upon existing literature and individual experience. After extensive debate, conclusion statements were deemed "consensus" if 85% of the group were in agreement and "unanimous" if 100% were in support. CONCLUSIONS: The group defined consensus terminology, agreed upon standardized templates for history and physical examination, and recommended a comprehensive approach to surgery. Early in the course of the disease, an orthopedic foot and ankle surgeon should be part of the care team. This consensus statement by a team of experienced orthopedic foot and ankle surgeons provides a comprehensive approach to the management of CMT cavovarus deformity. LEVEL OF EVIDENCE: Level V, expert opinion.

What Is the Impact of Periacetabular Osteotomy Surgery on Patient Function and Activity Levels?

BACKGROUND: Periacetabular osteotomy (PAO) is a hip preserving procedure performed often in younger, highly active patients. However, counseling patients is difficult, as there are limited data regarding activity level after PAO. The purpose of this study is to analyze the physical activity levels after PAO in a large, prospective multicenter cohort. METHODS: Prospectively collected data from a multicenter study group included 359 hips treated by PAO for hip dysplasia at a mean age of 25.1 years. Patient demographics, radiographic measures, operative data, and clinical outcomes were evaluated preoperatively, at 1 year, and at minimum 2 years postoperatively. Activity level was assessed with the University of California Los Angeles (UCLA) activity score, and patients were stratified into low activity, moderate activity, and high activity groups based on preoperative function. RESULTS: Compared to preoperative scores across the complete cohort, postoperative UCLA scores were improved on average 0.6 points at final follow-up (P = .001). The low activity and moderate activity groups had significant improvement in UCLA scores (P < .001 and P = .0007, respectively), while the high activity groups saw a significant decrease in UCLA activity scores (P < .0001). Modified Harris Hip Score, Hip Disability and Osteoarthritis Score Pain, and Hip Disability and Osteoarthritis Score Sports and Recreation scores were significantly improved across all preoperative activity levels. Multivariable linear regression (r2 = 0.45) confirmed prior ipsilateral surgery as a predictor for change in UCLA score (P = .002). CONCLUSION: Overall, these data suggest that consistent improvements in activity level and function can be expected following PAO surgery, with greater gains experienced by patients with lower preoperative levels of activity.

Extensor Tendon Transfers for Treatment of Foot Drop in Charcot-Marie-Tooth Disease: A Biomechanical Evaluation.

BACKGROUND: In Charcot-Marie-Tooth (CMT) disease, selective weakness of the tibialis anterior muscle often leads to recruitment of the long toe extensors as secondary dorsiflexors, with subsequent clawing of the toes. Extensor hallucis longus (EHL) and extensor digitorum longus (EDL) tendon transfers offer the ability to augment ankle dorsiflexion and minimize claw toe deformity. The preferred site for tendon transfer remains unknown. Our goal was to quantify ankle dorsiflexion in the "intact" native tendon state, compared with tendon transfers to the metatarsal necks or the cuneiforms. We hypothesized that EHL and EDL transfers would improve ankle dorsiflexion as compared with the intact state and would produce similar motion when anchored at the metatarsal necks or cuneiforms. METHODS: Eight fresh-frozen cadaveric specimens transected at the midtibia were mounted into a specialized jig with the ankle held in 20 degrees of plantarflexion. The EHL and EDL tendons were isolated and connected to linear actuators with suture. Diodes secured on the first metatarsal, fifth metatarsal, and tibia provided optical data for tibiopedal position in 3 dimensions. After preloading, the tendons were tested at 25%, 50%, 75%, and 100% of maximal physiologic force for the EHL and EDL muscles, individually and combined. RESULTS: Transfers to metatarsal and cuneiform locations significantly improved ankle dorsiflexion compared with the intact state. No difference was observed between these transfer sites. Following transfer, only 25% of maximal force by combined EHL and EDL was required to achieve a neutral foot position. CONCLUSION: Transfer of the long toe extensors, into either the metatarsals or cuneiforms, significantly increased dorsiflexion of the ankle. CLINICAL RELEVANCE: The transferred extensors can serve a primary role in treating foot drop in CMT disease, irrespective of the presence of clawed toes. This biomechanical study supports tendon transfers into the cuneiforms, which involves less time, fewer steps, and easier tendon balancing without compromising dorsiflexion power.

Radiographic and Magnetic Resonance Imaging of the Symptomatic Synthetic Cartilage Implant.

BACKGROUND: Synthetic Cartilage Implantation (SCI; Cartiva) is a treatment of hallux rigidus associated with mixed clinical outcomes in the United States. Patients with persistent pain typically undergo diagnostic imaging for evaluation. We aimed to characterize the radiologic findings of SCI and surrounding tissues. METHODS: This is a retrospective review of patients treated using SCI who underwent magnetic resonance imaging (MRI) for persistent pain. Metatarsophalangeal (MTP) joint spaces were compared on plain radiographs of the foot immediately postoperatively and at most recent follow-up. MRI of the foot were assessed for dimensions of the implant, bony channel, and presence of peri-implant fluid. Clinical follow-up, including Patient-Reported Outcome Measures Informational System (PROMIS) scores, satisfaction rating, and revision surgery, was collected. Eighteen cases of symptomatic SCI from 16 patients (13 females, 3 males) were included. All but 1 case involved a 10-mm implant. RESULTS: Mean satisfaction rating was 2.25 (1-5 Likert scale). PROMIS scores indicated moderate physical dysfunction (41) and moderate pain interference (63). Six of 16 patients (37.5%) underwent revision surgery at average 20.9 months of follow-up. Plain radiographs over a 13.3-month interval showed joint space narrowing of 2 mm medially and 1.6 mm laterally (P < .001). One hundred percent of cases had radiographic evidence of osteoarthritis (OA) progression. MRI studies were obtained on average 11.5 months postoperatively. The implant diameter averaged 9.7 mm, which mismatched the bony channel diameter of 11.2 mm (P < .001). Fourteen of 18 cases had peri-implant fluid. All cases had edema in the metatarsal, proximal phalanx, and soft tissues. CONCLUSION: Radiographic loss of MTP joint space and progression of arthritis were present for all cases studied. MRI revealed bony channel widening and a smaller implant, with peri-implant fluid suggesting instability at the implant-bone interface. Persistent edema was observed in soft tissues and bone. Diagnostic imaging of SCI in symptomatic patients demonstrated concerning findings that merit further correlation with patient outcomes. LEVEL OF EVIDENCE: Level IV, case series.

Does Previous Hip Arthroscopy Affect the Clinical Outcomes of Total Hip Arthroplasty?

BACKGROUND: Failure of hip arthroscopy procedures and the need for subsequent total hip arthroplasty (THA) have been estimated to be as high as 16%. Prior literature has shown that failed ipsilateral knee arthroscopy may have a negative impact on the functional outcome of subsequent total knee arthroplasty. To date, there is limited information regarding the impact of failed hip arthroscopy on the clinical outcomes of subsequent primary THA. PURPOSE: To compare clinical outcomes in primary THA between patients with and without prior arthroscopic hip surgery. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients undergoing primary THA with a history of ipsilateral hip arthroscopy were matched and compared in a 1:2 manner with patients undergoing primary THA without a history of hip arthroscopy. Patient-reported clinical outcomes were measured with the modified Harris Hip Score, the University of California-Los Angeles Activity Score, and 3 subscales from the Western Ontario and McMaster Universities Osteoarthritis Index (Pain, Stiffness, and Physical Function). RESULTS: At a mean follow-up of 42 months, there was no significant difference in any of the outcome measures between the 58 study hips and 116 matched controls. Additionally, both groups exhibited an absolute change in outcome scores that exceeded the minimum clinically important difference. CONCLUSION: Prior ipsilateral arthroscopic hip surgery does not adversely affect the clinical outcome of subsequent THA.

Yoga-Induced Myositis Ossificans Traumatica of the Scapholunate Ligament.

Background Myositis ossificans traumatica (MOT) involves the heterotopic development of lamellar bone after a traumatic injury. Despite being termed "myositis," MOT is not limited to muscle but rather can involve tendons, fat, and fascia. "Traumatica" reflects that lesions are usually associated with a history of significant trauma, that is, fractures or surgery; however, many reports suggest they can also be linked to repetitive low-energy insults. In both cases, the inflammatory response secondary to tissue injury generates a proliferative osteoblastic cascade. Case Description We present a case of persistent wrist pain in a 43-year-old woman associated with yoga activities. Her radiographic studies demonstrated partial scapholunate (SL) ligament tear and an associated mass lesion. Surgical pathology revealed MOT involving the SL ligament. Literature Review MOT lesions in the upper extremity are usually localized around the elbow, and cases in the hand are relatively rare. There are no prior reports of occurrences within the wrist joint or in association with the SL ligament. However, biomechanical studies have quantified significant mechanical strains across the SL interval during various yoga poses. This pattern of microtrauma is capable of generating MOT. Clinical Relevance Upper extremity weight-bearing positions are common in yoga and subject the wrist, especially the SL interval, to high mechanical strains. This pattern of microtrauma should lead the clinician to suspect MOT when encountering a mass in the wrist, but malignancy and infection must be ruled out.

Trends of hip arthroscopy in the setting of acetabular dysplasia.

Hip arthroscopy is increasingly utilized in the treatment of symptomatic intra-articular hip pathology. Unaddressed development dysplasia of the hip (DDH) is thought to be associated with failure after hip arthroscopy. The aims of this study were (i) to identify the prevalence of previous failed hip arthroscopy in patients undergoing a periactebaular osteotomy (PAO) for the treatment of symptomatic acetabular dysplasia, (ii) report on the temporal trend of failed ipsilateral hip arthroscopy in patients undergoing PAO and (iii) to determine clinical and radiographic characteristics associated with utilization of isolated hip arthroscopy in patients with acetabular dysplasia. We identified 139 patients undergoing PAO who had a history of a prior ipsilateral hip arthroscopy. A comparison group of 1505 patients with a diagnosis of acetabular dysplasia, who underwent PAO alone without any prior ipsilateral surgery during the study period was used. Clinical characteristics, radiographic and intraoperative findings were compared between cohorts. From 2008 to 2015, the rate of previous failed hip arthroscopy in patients undergoing subsequent PAO increased steadily until 2013 with a maximum of 12%. Patients in the study group had mild dysplasia with significantly higher LCEA (17.2° versus 11.3°; P < 0.001) and ACEA (15.6° versus 10.8°; P < 0.001), a lower acetabular inclination (14.0° versus 19.0°; P < 0.001). The findings illustrate a constant increase in the rate of failed hip arthroscopy in the setting of acetabular dysplasia from 2008 till 2013. Female sex and mild dysplasia were associated with use of isolated hip arthroscopy in the setting of acetabular dysplasia.

Comparison of Lateralizing Calcaneal Osteotomies for Varus Hindfoot Correction.

BACKGROUND: There is limited consensus on the optimal operative technique for correcting heel varus in patients with Charcot-Marie-Tooth (CMT) disease. This comparative study evaluated the ability of 4 lateralizing calcaneal osteotomies, with and without Dwyer wedge resection and coronal rotation of the posterior tuberosity, to correct severe heel varus. METHODS: The computed tomography (CT) scan of a teenage CMT patient with severe hindfoot varus was used to create 3-dimensional (3D)-printed models of the talus, calcaneus, and cuboid. A custom jig facilitated precise replication of the osteotomy cuts. Four different configurations were created: oblique osteotomy with lateralization, oblique osteotomy with lateralization and internal rotation of the posterior tuberosity, Dwyer wedge resection with lateralization, and Dwyer wedge resection with lateralization and internal rotation. CT scans were performed on each model before and after osteotomy. Statistical analysis was used to evaluate differences in several predefined radiographic parameters. RESULTS: The sequential transformations generated increasing lateral translation of the weight-bearing calcaneus. Dwyer wedge osteotomy significantly improved lateralization (effect = 8.0 mm), valgus hindfoot angle (effect = 6.1 degrees), and coronal calcaneal tilt (effect = -17.6 degrees) compared with the oblique osteotomy. Internal rotation of the posterior tuberosity further improved lateralization (effect = 3.3 mm), valgus hindfoot angle (effect = 2.5 degrees), and coronal calcaneal tilt (effect = -11.7 degrees). Dwyer osteotomy models had on average 5-mm shorter posterior tuberosity lengths than the oblique osteotomies. The addition of rotation did not significantly affect length. CONCLUSIONS: Significant lateralization of the posterior tuberosity was achieved in all transformations. The Dwyer wedge osteotomy improved hindfoot valgus angle, coronal calcaneal tilt, and lateralization of the weight-bearing surface compared with oblique osteotomy. Posterior tuberosity internal rotation further lateralized the plantar surface and normalized weight bearing. Lateralization, combined with Dwyer osteotomy and coronal plane internal rotation, achieved the greatest correction of varus heel. CLINICAL RELEVANCE: This study compares multiple lateralizing calcaneal osteotomies and proposes a combined technique of lateralization, Dwyer wedge resection, and coronal plane rotation to address advanced cavovarus hindfoot deformities.

Equivalent Clinical Outcomes Following Favored Treatments of Chronic Scapholunate Ligament Tear.

BACKGROUND: Optimal treatment of chronic scapholunate (SL) instability remains controversial. Many surgical techniques have been proposed with varied results in subsequent case series; however, there is limited evidence demonstrating the relative effectiveness of the different treatment options. QUESTIONS/PURPOSES: We conducted a systematic review of the English literature to compare outcomes from capsulodesis and ligament reconstruction for treatment of chronic scapholunate instability. METHODS: An electronic database search using keywords associated with scapholunate ligament instability was performed. A total of 511 studies were identified. All studies with scapholunate ligament tears >4 weeks after the initial injury were included in the review. Data extracted included patient demographics, wrist range of motion, and radiographic outcome measures. RESULTS: A total of 308 patients from 11 studies met the inclusion criteria and were included in the study. The average time to surgery from initial injury was 11 months. There was no significant difference in wrist flexion or extension after capsulodesis or reconstruction. The weighted mean for postoperative wrist extension/flexion was 56°/45.6° in the capsulodesis group and 40.9°/47.3° in the reconstruction group. Pooled means of SL angle and SL gap were 60.3° and 3.44 mm after capsulodesis and 56.5 and 2.72 mm after reconstruction, respectively. CONCLUSIONS: This systematic review failed to demonstrate any significant difference in outcomes from capsulodesis or reconstruction for treatment of chronic scapholunate instability. However, the retrospective studies examined were notably heterogeneous in design with high estimates of variance. Further prospective trials are necessary to determine an ideal treatment strategy.