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

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

Association Between Bone Mineral Density and Elderly Ankle Fractures: A Systematic Review and Meta-Analysis.

Ankle fractures are becoming increasingly more common in the elderly population and present a significant burden to the United States health care system. Many factors have been associated with fragility ankle fractures including age, gender, body mass index, diabetes, tobacco use, and osteoporosis. However, the literature is inconsistent regarding the relationship between ankle fractures and osteoporosis. The primary aim of this meta-analysis was to quantify the relationship between bone mineral density (BMD) in elderly patients with ankle fractures compared with BMD in elderly patients without ankle fractures. A literature search was undertaken using relevant search terms. Articles were screened for suitability and data extracted where studies met inclusion criteria and were of sufficient quality. Data were combined using standard meta-analysis methods. Seven studies were used in the final analysis. A small-pooled effect size was found indicating the control group had increased BMD regardless of measurement used (95% confidence interval 0.09-0.58; I2 = 98.39%). Lower femoral neck BMD showed a small-pooled effect size (femoral neck 0.36; 95% confidence interval 0.00-0.73; I2 = 94.91%) with the ankle fracture cohort. This is the first meta-analysis to quantify the relationship between BMD and ankle fractures in the elderly population. Elderly ankle fractures showed a significant association with femoral neck BMD. The current data can be used in orthopedic clinics and Fracture Liaison Service programs to assign the appropriate subgroup of ankle fracture patients to investigative and treatment groups, assess fracture risk, and serve as an indication for secondary fracture prevention by stimulating an osteoporosis prevention workup. There may be a role for a team approach to fracture care including metabolic optimization.

Clinical Implications of a One-hand Versus Two-hand Technique in the Silfverskiöld Test for Gastrocnemius Equinus.

Introduction Isolated gastrocnemius equinus contracture has been associated with several foot and ankle pathologies within the literature. The Silfverskiöld test is commonly used to identify isolated gastrocnemius contracture, however, the proper technique for performing the test has been scrutinized. The purpose of this study was to determine if there is a clinical significance in the ankle dorsiflexion that is obtained when the examination is performed incorrectly with a single hand versus the correct two-hand technique. Methods Thirty consecutive new patients with conditions associated with gastrocnemius equinus were included in the study. The Silfverskiöld test was performed with a two-hand technique and a single-hand technique. The amount of dorsiflexion obtained with the knee in full extension was measured and recorded using an extendable goniometer for each technique, with the arms aligned with the fifth metatarsal and fibular head. Results The average amount of dorsiflexion that was obtained with the two-hand technique with the knee in full extension was 76.3°±4.2°. When the one-hand technique was utilized the average amount of dorsiflexion obtained with the knee in full extension was 88.4°±4.2°. This was found to be statistically significant (p<0.01). Conclusion This study demonstrates that if the Silfverskiöld test is not performed correctly, the diagnosis of an isolated gastrocnemius contracture could be underappreciated. Accordingly, it may be important to perform the test with two hands in order to neutralize the hindfoot, midfoot, and forefoot, so that the dorsiflexion motion is through the tibiotalar joint alone.

Ankle Arthrodesis With Structural Grafts Can Work for the Salvage of Failed Total Ankle Arthroplasty.

Background. Treatment options after failed total ankle arthroplasty (TAA) are limited. This study reports midterm outcomes and radiographic results in a single-surgeon group of patients who have undergone ankle arthrodesis with intramedullary nail fixation and structural allograft augmentation following failed TAA. Methods. A retrospective review on patients who underwent failed TAA revision with structural femoral head allograft and intramedullary tibiotalocalcaneal (TTC) nail fixation was completed. Foot Function Index (FFI), American Orthopaedic Foot & Ankle Society (AOFAS) outcome scores, and radiographs were obtained at each visit with 5-year follow-up. Results. Five patients were followed to an average of 5.2 years (range 4.7-5.6). Enrollment FFI was 34.82 (range 8.82-75.88); at midterm follow-up it was 20.42 (range 0-35.38). Enrollment AOFAS scores averaged 66.6 (range 61-77); at midterm follow-up it was 70.33 (range 54-88). Radiographs showed union in 4 of 5 patients at enrollment and 2 of 3 patients at midterm. Conclusions. Utilization of TTC fusion with femoral head allograft is a salvage technique that can produce a functional limb salvage. Our results show continued improvement in patient-reported outcomes, with preservation of limb length and reasonable union rate. Levels of Evidence: Therapeutic, Level II: Prospective, comparative trial.

Maintenance of Correction of the Modified Lapidus Procedure With a First Metatarsal to Intermediate Cuneiform Cross-Screw Technique.

BACKGROUND: Recurrence of deformity remains a concern when fusing the first tarsometatarsal joint for correction of hallux valgus (HV). A recently described construct adds an additional point of fixation from the plantar medial first metatarsal to the intermediate cuneiform. The purpose of this study was to determine the maintenance of correction of the first and second intermetatarsal angle, hallux valgus angle, and tibial sesamoid position after undergoing a first tarsometatarsal joint arthrodesis using the proposed construct. METHODS: A radiographic review was performed of patients with HV treated with a first tarsometatarsal joint arthrodesis with the addition of a cross-screw intermediate cuneiform construct. Three observers reviewed radiographic data, including preoperative weightbearing, first weightbearing, and final weightbearing plain-film radiographs. Initial improvement and maintenance of intermetatarsal angle, hallux valgus angle (HVA), and tibial sesamoid position were evaluated radiographically. A total of 62 patients met inclusion criteria and were included in the study. Mean follow-up time was 9.3 months (SD 6.7). RESULTS: Bony union was achieved in 60 of 62 patients (96.7%). Two of 62 patients required revision surgery as a result of recurrence (3.3%). Final mean improvement of the intermetatarsal angle (IMA) was 6.8 degrees (±2.9 degrees), HVA was 14.8 degrees (±7.5 degrees), and tibial sesamoid position was 2.4 (±1.4) positions. Mean loss of IMA correction was 1.5 degrees (±1.6), HVA was 2.9 degrees (±4.8 degrees), and tibial sesamoid position was 0.8 (±0.8). CONCLUSION: This study showed that the cross-screw intermediate cuneiform construct for first tarsometatarsal joint arthrodesis had a good union rate, a low complication rate, and maintained radiographic correction. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Outcomes of Primary Tibiotalocalcaneal Nailing for Complicated Diabetic Ankle Fractures.

BACKGROUND: Ankle fractures in patients with complicated diabetes have significantly increased the rates of complications and poorer functional outcomes when treated nonoperatively, and there have been only modest reductions when treated operatively. We hypothesized that the minimally invasive, robust construct that tibiotalocalcaneal fixation with an intramedullary nail offers would result in high rates of limb salvage, acceptable rates of complications, and less loss of function, in this difficult patient population. METHODS: This was an institutional review board-approved retrospective study of 27 patients with complicated diabetes who underwent tibiotalocalcaneal nailing of their ankle fracture as a primary treatment without formal joint preparation. Patients with complicated diabetes were defined as having neuropathy, nephropathy, and/or peripheral vascular disease. The mean clinical follow-up was 888 days. Patients were screened for associated risk factors. Data were collected on surgical complications. The outcomes measured included length of hospital stay, loss of ambulatory level, amputation, and time to death. The mean age was 66 years with an average body mass index of 38 and hemoglobin A1c of 7.4. Six fractures were open. RESULTS: The limb salvage rate was 96%. The average hospital stay was 6 days, and the mean time to weightbearing was 6.7 weeks. The fracture union rate was 88%. The surgical complication rate was 18.5%, with no instances of malunions, symptomatic nonunions, or Charcot arthropathy. Eight patients died by final follow-up (mean, 1048 days). An ambulatory level was maintained in 81% of the patients. CONCLUSION: With high limb salvage rates, relatively early weightbearing, maintained ambulatory level, and acceptable complication rates, we believe our technique can be considered an appropriate approach to increase the overall survivability of threatened limbs and lives in this patient population. LEVEL OF EVIDENCE: Level IV, retrospective case series.

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

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

Spontaneous Compartment Syndrome in a Patient with McArdle Disease: A Case Report and Review of the Literature.

CASE: McArdle disease, a glycogen storage disorder, often manifests as exercise intolerance secondary to muscle ischemia. Few authors have reported on rhabdomyolysis or compartment syndrome following inciting events among patients with McArdle disease. We present the case of a 40-year-old woman who developed spontaneous compartment syndrome of the right forearm and subsequently underwent emergency fasciotomy. CONCLUSION: On the basis of the present case and our review of the current literature, we advocate a high level of suspicion for compartment syndrome in patients with a history of McArdle disease.

Arthroscopically Assisted Reduction and Internal Fixation of a Displaced Posterior Glenoid Fracture: A Case Report.

CASE: We report the successful use of arthroscopy for reduction and internal fixation of a posterior glenoid fracture in a 62-year-old man 5 days following a skiing accident. Additionally, we review the technique utilized for successful fixation of this rare fracture, and we report the postoperative return of function. CONCLUSION: Arthroscopically facilitated fixation of glenoid fractures has been reported in the literature with excellent clinical outcomes. However, arthroscopic reduction and screw fixation of a posterior intra-articular glenoid fracture (Ideberg type Ib), to our knowledge, has not been previously published. The unique benefits of arthroscopic screw fixation are discussed.

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

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

Relationship between development of post-thrombotic syndrome and serial ultrasound, D-dimer, and factor VIII activity after a first deep venous thrombosis.

OBJECTIVE: The aim of this study was to evaluate the relationship of post-thrombotic syndrome (PTS) with residual vein thrombosis, deep venous reflux (DVT), D-dimer, and factor VIII (FVIII) after a first deep venous thrombosis (DVT). METHODS: There were 133 participants with objectively confirmed DVT, of whom 114 were observed for 6 months after completion of anticoagulation. Ultrasound, D-dimer, and FVIII evaluations were undertaken at 6 weeks after completion of anticoagulation and at the end of follow-up. PTS was considered present in those with a score of ≥5 on the Villalta scale at either assessment. RESULTS: The cumulative incidence of PTS was 51.8%, with median duration of follow-up of 11 months. Median D-dimer and FVIII in those with PTS were significantly higher at both time points compared with those without. Similarly, residual vein thrombosis and deep venous reflux were more prevalent in those with PTS at both study assessments. On multivariable analysis, only FVIII at end of study remained significantly associated with PTS with an odds ratio of 2.83 (95% confidence interval, 1.09-7.42; P = .034). Ultrasound markers and D-dimer were not significantly associated with PTS after adjustment for age, body mass index, Charlson Index ≥1, and proximal extent of DVT. CONCLUSIONS: FVIII activity at end of follow-up was independently associated with PTS, suggesting underlying activation of coagulation.