Midfoot Trauma: Let's Get It Right the First Time.

Lisfranc injuries represent a wide variety of injury patterns, from stable midfoot sprains to grossly displaced fractures and fracture-dislocations. Obtaining and maintaining an anatomic reduction is critical in the treatment of these injuries. Considerable controversy remains as to the optimal method of treatment. Beyond the type and severity of the injury pattern, treatment decisions may ultimately be defined by activity-specific criteria and patient demographics.

Medial talar resection: how much remains stable?

PURPOSE: Pathologies of the medial talus (e.g., fractures, tarsal coalitions) can lead to symptomatic problems such as pain and nonunion. Bony resection may be a good solution for both. It is unclear how much of the medial talus can be taken before the subtalar joint becomes unstable. The aim of this study was to evaluate the effect a limited resection of the medial talar facet and the anteromedial portion of the posterior talar facet has on subtalar stability. METHODS: Eight fresh-frozen human cadaveric lower limbs were mounted in a frame for simulated weight-bearing. Computed tomography scans were obtained under 700 N single-legged stance loading, with the foot in neutral, 15° inversion, and 15° eversion positions. A sequential resection of 10, 20, and 30% of the medial facet and the anteromedial portion of the posterior talar facet to the calcaneus, based on the intact talus width, was performed. Measurements of subtalar vertical angulation, talar subluxation, coronal posterior facet angle and talocalcaneal (Kite) angle in the anteroposterior and lateral view were performed. RESULTS: Gross clinical instability was not observed in any of the specimens. No significant differences were detected in the measurements between the resected and intact states (P ≥ 0.10) as well as among the resected states (P ≥ 0.11). CONCLUSION: In a biomechanical setting, resecting up to 30% of the medial facet and anteromedial portion of the posterior facet based on the intact talus width-does not result in any measurable instability of the subtalar joint in presence of intact ligamentous structures. LEVEL OF EVIDENCE: V.

Macrodystrophia Lipomatosa of the Foot: A Case Report of MRI and Histologic Findings Including Pacinian Corpuscle Abnormalities.

CASE: A 37-year-old man presented with pain and macrodactyly of a toe. Imaging and histology demonstrated findings consistent with macrodystrophia lipomatosa (MDL). We compared our findings with control tissue obtained from an identical site of a fresh-frozen cadaveric foot from the same anatomical site. Pacinian corpuscles (PCs) in the MDL tissue were increased in number, size, and shape compared with the control tissue and demonstrated edematous interstitial lamellae and vacuolar degenerative change. We also document the magnetic resonance imaging findings of the PCs. CONCLUSION: Peculiar abnormalities of PCs in MDL underline nerve damage and may be a contributing factor in the pain associated with this unusual condition.

Finding NEEMO: towards organizing smart digital solutions in orthopaedic trauma surgery.

There are many digital solutions which assist the orthopaedic trauma surgeon. This already broad field is rapidly expanding, making a complete overview of the existing solutions difficult.The AO Foundation has established a task force to address the need for an overview of digital solutions in the field of orthopaedic trauma surgery.Areas of new technology which will help the surgeon gain a greater understanding of these possible solutions are reviewed.We propose a categorization of the current needs in orthopaedic trauma surgery matched with available or potential digital solutions, and provide a narrative overview of this broad topic, including the needs, solutions and basic rules to ensure adequate use in orthopaedic trauma surgery. We seek to make this field more accessible, allowing for technological solutions to be clearly matched to trauma surgeons' needs. Cite this article: EFORT Open Rev 2020;5:408-420. DOI: 10.1302/2058-5241.5.200021.

Axial and shear pullout forces of composite, porcine and human metatarsal and cuboid bones.

OBJECTIVES: The varying mechanical properties of human bone have influence on the study results. Pullout and shear forces of human bone were compared to different substitutes to evaluate their suitability for biomechanical studies. METHODS: After bone mineral density (BMD) determination, axial pullout tests were performed with cortical 3.5 mm nonlocking (NL) and 2.7 mm head locking (HL) screws on human, porcine and polyurethane composite bones. Porcine and human constructs were additionally loaded in shear direction. RESULTS: Apparent BMD was significantly lower in osteoporotic (159 mgHA/ccm ± 56) and nonosteoporotic (229 mgHA/ccm ± 25) human bone than that in porcine bone (325 mgHA/ccm ± 42; p < 0.01). Axial construct stiffness and ultimate pullout force of porcine bone (NL: 666N/mm ± 226, 910N ± 140; HL: 309N/mm ± 88, 744N ± 185) was significantly different from composite bone (NL: 1284N/mm ± 161; 1175N ± 116; HL: 1241N/mm ± 172, 1185N ± 225) and osteoporotic human bone (NL: 204N/mm ± 121, 185N ± 113; HL: 201N/mm ± 65; 189N ± 58) but not from nonosteoporotic human bone (NL: 620N/mm ± 205, 852N ± 281; HL: 399N/mm ± 224; 567N ± 242). Porcine bone exhibited an ultimate shear force (NL: 278N ± 99; HL: 431N ± 155) comparable to nonosteoporotic human bone (NL: 207 ± 68: HL: 374N ± 137). CONCLUSION: Screw pullout and shear forces of porcine bone are close to nonosteoporotic human bone. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE: Human bone specimens used in biomechanical studies are predominantly of osteoporotic bone quality. Conclusions on nonosteoporotic human bone behaviour are difficult. Alternatives such as porcine bone and composite bone were investigated, and it could be shown that screw pullout and screw shear forces of porcine bone are close to nonosteoporotic human bone.

Reliability, validity and responsiveness of the Spanish Manchester-Oxford Foot Questionnaire (MOXFQ) in patients with foot or ankle surgery.

BACKGROUND: The Manchester-Oxford Foot Questionnaire (MOXFQ) has been validated in Spanish for use in patients undergoing foot and ankle surgery. METHODS: 120 patients completed the MOXFQ and the SF-36 before surgery and 6 and 12 months postoperative. Surgeons completed the American Orthopaedic Foot and Ankle Society (AOFAS) Clinical Rating System. Psychometric properties were assessed for all three MOXFQ dimensions, and for the MOXFQ Index. RESULTS: The Spanish MOXFQ demonstrated consistency with Cronbach's alpha values between 0.65 and 0.90, and reliability ([ICCs] >0.95). It shows a moderate to strong correlation between the Walking/standing dimension and the related domains of the SF-36 (|r|>0.6), the AOFAS Ankle-Hindfoot Scale (|r|>0.47) and Hallux-MTP-IP Scale (|r|>0.64). Responsiveness was excellent, (effect sizes >2.1). The respective minimal detectable change (MDC90) was 14.18 for the MOXFQ Index. CONCLUSIONS: The Spanish version of the MOXFQ showed good psychometric properties in patients with foot and ankle disorders.

Tibiotalocalcaneal fusion using the hindfoot arthrodesis nail: a multicenter study.

BACKGROUND: Tibiotalocalcaneal arthrodesis is a salvage option for severe ankle and hindfoot deformities, arthritis of the ankle and subtalar joints, avascular necrosis of the talus, failed total ankle arthroplasty, and Charcot arthropathy. This multicenter study reports clinical experience with the hindfoot arthrodesis nail (HAN) in the treatment of patients with severe ankle and foot abnormalities. METHODS: Seven participating clinics from Europe and North America recruited 38 patients who underwent ankle/subtalar arthrodesis using retrograde nailing with the HAN. Information was collected regarding technical details, complications, and functional and quality of life outcomes (Short Form-36 [SF-36], American Academy of Orthopaedic Surgeons-Foot and Ankle Outcomes [AAOS-FAO], and numeric rating scale [NRS] for pain) after an average of 2 years of follow-up. RESULTS: The rate of superficial wound infection was 2.4%. No deep soft tissue or bone infections were reported. The overall union rate was 84%. At the time of follow-up, low pain levels were reported, with a mean NRS of 2.2; the mean AAOS-FAO score was 38; and the SF-36 mean physical and mental health component scores were 41.2 and 52.5, respectively. All 13 patients who were unable to work prior to surgery were able to fully return to work. CONCLUSIONS: The HAN offered a safe and reliable salvage option for tibiotalocalcaneal arthrodesis in patients with severe ankle and hindfoot disease. It achieved acceptable functional outcome and low complication rates despite the challenging patient cohort. A considerable socioeconomic benefit appeared to result based on the high proportion of patients who were able to return to work postoperatively. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Lateral column lengthening.

The guiding principle behind the lateral column lengthening is to bring the forefoot and midfoot out of abduction while using the foot's natural bony architecture to drive the hindfoot into inversion and dorsiflexion. This correction effectively negates the loss of normal biomechanics created by the loss of the dynamic function of the posterior tibial tendon. The purpose of this article is to review the lateral column lengthening procedure through a detailed explanation of the operation, the postoperative care, and the pitfalls and complications of the procedure.

Neovascularity in chronic posterior tibial tendon insufficiency.

Insufficient posterior tibial tendons in 28 specimens from patients with clinical Stage II or III disease were examined to clarify the etiology of adult-acquired flatfoot deformity. Hematoxylin and eosin and Masson trichrome-stained sections of formalin-fixed tissue were viewed in plain and polarized light. We performed a qualitative analysis for abnormalities in collagen orientation, degree of vascularization, tenocyte cellularity, mucinous change, and chondroid metaplasia. Tendons were divided into three zones: tenosynovial lining cell layer, subtenosynovial lining cell layer, and tendon proper. All tendons showed neovascular infiltration causing collagen fibril disruption; 50% of specimens had diffuse involvement. Increased mucin content and chondroid metaplasia occurred in 28% and 36% of specimens, respectively. The tenosynovial lining cell layer showed hyperplasia in 28% of specimens. The subtenosynovial lining cell layer showed thickening and neovascularization in 79% of specimens, which appeared to be the source for the diffuse neovascular infiltrative process. There is little histopathologic evidence to support an inflammatory etiology to the posterior tibial tendons in acquired-adult flatfoot deformity. Neoangiogenesis, the prominent histologic finding, is consistent with an obscure insult. We postulate that overuse, tension, or stretching may activate the tenosynovial lining cells and incite angiogenesis.

Reliability of the Foot Function Index:: A report of the AOFAS Outcomes Committee..

BACKGROUND: There currently is no widely used, validated, self-administered instrument for measuring musculoskeletal functional status in individuals with nonsystemic foot disorders. The purpose of this paper was to report on the assessment of reliability of one of these instruments. We wanted to determine if the Foot Function Index (FFI), which has been validated in rheumatoid patients without fixed foot deformity or prior foot surgery, would be reliable for a population of patients with foot complaints without systemic disease. METHODS: Patients were recruited from five orthopaedic offices where the physicians were members of the American Orthopaedic Foot and Ankle Society. Patients were asked to complete the FFI at the time of their initial office visit and then were given a second copy to complete and return by mail 1 week after their visit. RESULTS: Ninety-six patients completed the first questionnaire, and 54 patients completed the second. Reliability in this population was acceptable with an average of 23.5% of the patients providing retest values within one point of the initial response and an average of 45.3% of the patients providing the same response, for a total of 68.8% of all respondents answering within one point between their initial and second questionnaire. In two of the three categories, there were frequent nonresponses or no applicable responses. Four questions, two in the pain section and two in the activity limitation section, generated 20% or more of the nonapplicable answers. CONCLUSIONS: The FFI appears to be a reasonable tool for low functioning individuals with foot disorders. It may not be appropriate for individuals who function at or above the level of independent activities of daily living.

Issues of importance to patients seeking care from members of the AOFAS: a preliminary report of the outcomes committee of the AOFAS.

BACKGROUND: The purpose of this multi-center study was to examine the outcomes of importance for patients seeking treatment for foot and ankle disorders. An improved understanding of patient outcome preferences will assist surgeons in improving patient satisfaction. METHODS: An open-ended priority function questionnaire was administered to 235 patients presenting as new patients to five different outpatient locations. The questionnaire was designed to identify activities of importance to patients and was based on the McMaster Toronto Arthritis (MACTAR) patient preference disability questionnaire. Subjects were asked to list the specific activities that were limited by their condition. Open-ended answers were written on five blank spaces and then ranked as to their importance. The visual analog pain scale was recorded as a measure of the severity of the patient's symptoms at the time the response was made. The outpatient settings were two university hospitals, two private offices with academic affiliation, and one private office. Two hundred thirty-five surveys were collected between September and November of 2000; 227 surveys were acceptable for analysis. The respondents included 132 females (58.1%), 94 males (41.4%) and one patient who did not specify his gender (0.4%). The mean age was 45.8 (range 18 to 83) years. RESULTS: Average pain at the time of assessment was 2.7 on a scale of 0 to 9 and was reported to increase to 4.8 in a typical day. The most frequently ranked limitations were difficulty with walking (159), running (73), standing (55), and exercise (54). Walking also was the issue ranked as the highest priority (77 of 159), while running (11 of 73), standing (10 of 55) and exercise (3 of 54) were assigned lesser priority values. Only 68 of 227 respondents failed to list walking as an issue. Work, sleep, and social activities were not commonly cited as issues of importance. CONCLUSION: Patients presenting to office practices identified as specializing in foot and ankle disorders are predominantly middle-aged women in mild to moderate pain. Walking is the function most frequently identified as a problem and ranked as the highest priority for improvement. Social limitations were unlikely to be named as a limitation in this population.

Fracture of the lateral process of the talus: a report of 2 cases.

Fracture of the lateral process of the talus is historically a rare injury with an increasing incidence. This fracture is easily misdiagnosed as an ankle soft-tissue sprain, and a high index of suspicion is essential in making a timely diagnosis to avoid any long-term sequelae. A CT scan should be performed in preference over an MRI scan.

Integral classification of injuries (ICI) to the bones, joints, and ligaments--application to injuries of the foot.

The integral classification of injuries (ICI) is a very logical, descriptive classification of fractures and dislocations of the human skeleton. By enumerating all 28 foot bones in relation to the three anatomical and functional regions of the foot, ie, hindfoot (81), midfoot (82), forefoot (83), from proximal to distal, and by introducing lowercase letters for the joints of the foot skeleton,the localization of the injury can be described precisely. The uppercase A defines extra-articular, B describes intra-articular and C is for fracture dislocations. By introducing the uppercase D, different dislocations can be described. By using additional lowercase Greek letters, the direction of a dislocation can be coded. For simple 'everyday' use, a fracture of the calcaneus(81.2) involving three joints can be described as a B3-fracture. For scientific or database coding purposes, one can describe in square brackets which joints or segments are involved and how they are injured in relation to three different subgroups representing first the tissue (bone, cartilage, capsule, and ligaments),second the kind of injury (three graduations of fracture, cartilage, or ligament damage), and third (three graduations) the extent of the dislocation or displacement. Following ten conventions, a complex foot trauma can be coded as precisely as a simple dislocation of the big toe.

Lisfranc injuries.

Lisfranc/midfoot injuries are complex injuries that are frequently overlooked. The consequences of missing these injuries can lead to long-term deformity and disability. Timely diagnosis, whether by primary or later treating physicians, can ensure this does not happen. Proper physical examination and imaging studies allow the physician to find these injuries and determine if open treatment is required. Open treatment can be approached and performed in a number of ways, depending on geographical preference. However, one concept that remains across all the various techniques is perfect anatomical reduction before the fixation technique is applied. Intraoperative and postoperative variations are all secondary concerns after anatomical reduction.

Technique for percutaneous insertion of intramedullary nail for intertrochanteric hip fracture.

Intramedullary nailing has been proven to have biomechanical advantages over the use of a side plate and screw system. Further advantages may be gained with the use of a percutaneous technique, thereby minimizing blood loss, operative time, and overall morbidity. This article describes a technique for inserting an intramedullary nail percutaneously using a minimal-incision technique by utilizing fluoroscopy in cases of intertrochanteric hip fracture.

Lateral-sided bony procedures.

Treatment of any hindfoot deformity should include correction of the deformity and preservation of complex hindfoot motion. This important motion is protective of adjacent, and more removed, joints in that it serves a shock-absorbing function and protects them from stresses. Lateral column lengthening combined with a medial soft-tissue procedure is the treatment of choice for stage II flat foot. Patients who have significant subluxation of the subtalar joint will also need a medial displacement calcaneal osteotomy to correct the hindfoot valgus. Only patients who have a rigid foot secondary to degenerative changes will require an arthrodesis to correct the deformity and provide pain relief. Unfortunately, although fusion works well to correct deformity, it accelerates future degenerative changes.