First Tarsometatarsal Joint Fusion in Foot-A Biomechanical Human Anatomical Specimen Analysis with Use of Low-Profile Nitinol Staples Acting as Continuous Compression Implants.

Background and Objectives: The aim of this study was to investigate under dynamic loading the potential biomechanical benefit of simulated first tarsometatarsal (TMT-1) fusion with low-profile superelastic nitinol staples used as continuous compression implants (CCIs) in two different configurations in comparison to crossed screws and locked plating in a human anatomical model. Materials and Methods: Thirty-two paired human anatomical lower legs were randomized to four groups for TMT-1 treatment via: (1) crossed-screws fixation with two 4.0 mm fully threaded lag screws; (2) plate-and-screw fixation with a 4.0 mm standard fully threaded cortex screw, inserted axially in lag fashion, and a 6-hole TMT-1 Variable-Angle (VA) Fusion Plate 2.4/2.7; (3) CCI fixation with two two-leg staples placed orthogonally to each other; (4) CCI fixation with one two-leg staple and one four-leg staple placed orthogonally to each other. Each specimen was biomechanically tested simulating forefoot weightbearing on the toes and metatarsals. The testing was performed at 35-37 °C under progressively increasing cyclic axial loading until construct failure, accompanied by motion tracking capturing movements in the joints. Results: Combined adduction and dorsiflexion movement of the TMT-1 joint in unloaded foot condition was associated with no significant differences among all pairs of groups (p ≥ 0.128). In contrast, the amplitude of this movement between unloaded and loaded foot conditions within each cycle was significantly bigger for the two CCI fixation techniques compared to both crossed-screws and plate-and-screw techniques (p ≤ 0.041). No significant differences were detected between the two CCI fixation techniques, as well as between the crossed-screws and plate-and-screw techniques (p ≥ 0.493) for this parameter of interest. Furthermore, displacements at the dorsal and plantar aspects of the TMT-1 joint in unloaded foot condition, together with their amplitudes, did not differ significantly among all pairs of groups (p ≥ 0.224). Conclusions: The low-profile superelastic nitinol staples demonstrate comparable biomechanical performance to established crossed-screws and plate-and-screw techniques applied for fusion of the first tarsometatarsal joint.

Salvage of Failed Lisfranc/Midfoot Injuries.

Salvage of Lisfranc, or tarsometatarsal injuries, may be necessary because of a variety of clinical scenarios. Although rare, these injuries represent a broad spectrum of injury to the midfoot ranging from low-energy ligamentous injuries to high-energy injuries with significant displacement and associated fractures. Poor outcomes and complications may occur including posttraumatic arthritis, instability, pain, infection, and loss of function. Strategies and technical considerations for salvage of these complex injuries are provided.

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.

Calcaneal Fractures-Which Approach for Which Fracture?

Treatment of calcaneal fractures has to be tailored to the individual pathoanatomy. If operative treatment is chosen, anatomic reconstruction of the calcaneal shape and joint surfaces is mandatory. For most of the displaced, intraarticular fractures, this can be achieved by less invasive reduction and fixation via a sinus tarsi approach, which may be extended along the "lateral utility" line for calcaneocuboid joint involvement or calcaneal fracture-dislocations. Purely percutaneous fixation is the treatment of choice for displaced extraarticular fractures and simple intraarticular fractures with adequate control of joint reduction. Specific approaches are used for rare calcaneal fracture variants.

Recognition, Treatment, and Outcome of Calcaneal Fracture-Dislocation.

BACKGROUND: Calcaneal fracture-dislocations are rare but potentially disabling injuries that are regularly overlooked at first presentation. To date, only about 50 cases have been reported in the literature. METHODS: Over a period of 8 years, 10 patients (average age 61.7 years) with acute fracture-dislocations of the calcaneus were treated at 2 level 1 trauma centers. The calcaneocuboid joint was involved in 9 patients. There was a concomitant fracture of the lateral talar process and of the tip of the distal fibula in 7 patients each. Open reduction and internal fixation was performed in 9 of 10 patients via an oblique lateral dislocation approach. One patient underwent primary subtalar fusion. All patients were seen for clinical and radiographic follow-up at an average of 3 years using patient-reported outcome scores. RESULTS: Anatomic fixation was achieved in all patients as judged by postoperative computed tomographic imaging. In the 9 patients treated with internal fixation, the Foot Function Index averaged 12.8, the EuroQol 5D score averaged 0.89 and the visual analog scale score for patient satisfaction averaged 79.3 at final follow-up. Signs of mild subtalar arthritis were seen in 6 patients. No secondary subtalar fusions were needed. CONCLUSION: When recognized and treated early, prognosis of calcaneal fracture-dislocation was favorable. A dislocation approach starting over the distal fibula, continuing over the sinus tarsi, and extending toward the calcaneocuboid joint allowed for adequate visualization of the subtalar joint and treatment of all components of the injury. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Indications and Surgical Treatment of Acute and Chronic Tibiofibular Syndesmotic Injuries with and Without Associated Fractures.

Syndesmosis injury may occur in a wide variety of clinical scenarios. Accurate diagnosis and anatomic reconstruction are necessary for optimizing clinical outcomes. The management considerations of syndesmotic injuries with associated proximal fibula fractures are reviewed. Methods to improve the accuracy of syndesmotic reduction are outlined. The management of fractures of the posterior malleolus, Chaput tubercle, and Wagstaffe tubercle is discussed with an emphasis on their contributions to syndesmotic stability. The evolving role of flexible fixation for syndesmosis injuries is discussed. Causes and strategies for dealing with loss of reduction and malreduced syndesmotic injuries are presented.

Endoscopic Flexor Hallucis Longus Transfer for Achilles Noninsertional Tendinopathy: Description of Surgical Technique and Functional Outcomes.

Background. The transfer of the flexor hallucis longus (FHL) tendon is an established treatment for replacing a dysfunctional Achilles tendon. Objectives. (1) Describe a new technique for endoscopic FHL transfer for noninsertional Achilles tendinopathy and (2) describe the functional outcomes and complications after endoscopic and open FHL transfer. Materials and Method. Retrospective study of patients who underwent open or endoscopic FHL transfer between 2014 and 2016. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle/hindfoot scale was used preoperatively and postoperatively to measure the functional results. Results. We included 18 endoscopic FHL transfers and 24 open FHL transfers. The mean age of endoscopic and open procedures was 47.5 years (range 25-77 years) and 61.2 years (range 43-72 years), respectively. An improvement on the average AOFAS of 52.8% (31.9 points) was observed in the endoscopy group during the follow-up from the baseline. The mean improvement in AOFAS score for the open group was 41.4% (24.5 points). Four and 7 cases reported complications in the endoscopy and open FHL transfer groups, respectively. Conclusion. While both procedures were effective in treating noninsertional Achilles tendinopathy, the described arthroscopic treatment led to a greater improvement in the AOFAS score and is slightly less prone to lasting complications.Level of Evidence: Level IV: Case series.

Three-Dimensional Imaging of Displaced Intra-articular Calcaneal Fractures Correlates With the Perioperative Diagnosis.

BACKGROUND: Intra-articular calcaneal fractures are complex injuries, and CT imaging has become the standard imaging in the preoperative assessment. Most classifications of these fractures are CT-based but have been associated with limited interobserver agreement. Three-dimensional imaging has become widely available and may give a better perspective but often with 1 image only. There is not much evidence of the added value of this imaging, compared with the CT imaging. METHODS: Eight experienced trauma surgeons assessed 28 different intra-articular calcaneal fractures, on conventional radiology (CR), CT, and 3-D imaging. All had extensive experience in the diagnosis and treatment of this difficult injury. The main questions concerned Sanders classification, the severity of the injury and the difficulty of the operative procedure, choice of approach, and choice of procedure. RESULTS: The classical 2-D CT imaging of the fractures were associated with a higher Sanders classification ranking, compared with the 3-D imaging scores. However, the interobserver agreement, as measured by the Fleiss kappa, was low for all 3 imaging modalities. We found more frequent Sanders III and IV classifications with CT scan imaging compared with 3-D imaging or CR. The scores obtained after assessing 3-D imaging were also not statistically significantly different from the scores of a consensus achieved by 2 authors and based on the 3 imaging modalities and the perioperative diagnosis. CONCLUSION: The 3-D imaging may result in a more realistic view, reducing the frequency of classifying Sanders III fractures than with the 2-D CT imaging series. 3-D imaging may be more reliable than CT in the planning of operative treatment of displaced intra-articular calcaneal fractures. LEVEL OF EVIDENCE: Level III.

Late Treatment of Displaced Intra-Articular Calcaneus Fractures: Successful Management With Anatomic Reduction.

INTRODUCTION: The aim of this study was to evaluate the results of displaced intra-articular calcaneus fractures treated more than 25 days after injury by open reduction and internal fixation (ORIF) using a lateral extensile surgical approach. METHODS: Twenty patients identified by retrospective review of our trauma database were treated with ORIF for a displaced intra-articular calcaneus fracture more than 25 days after injury. OTA/AO 82-B and 82-C fracture patterns were included. All had ORIF by a lateral extensile approach. Bohler's angle was measured on injury radiographs, after operative fixation and the final follow-up and compared with the Bohler's angle of the contralateral uninjured extremity. Patients completed a Musculoskeletal Function Assessment (MFA) to evaluate the functional outcome. RESULTS: The mean number of days from injury to fixation was 33.4 days (range, 26-58 days). A total of 18/20 patients were available for follow-up (mean 26.1 months; range 12.5-100 months). Eleven injuries were joint depression (82-C), and 7 injuries were tongue type (82-B) fracture patterns. The reason for delayed presentation was delayed transfer to our institution (11 patients), hemodynamic instability from polytrauma (2 patients), excessive fracture blisters (2 patients), and sepsis (1 patient). Bohler's angle at the time of injury was a mean of 10.9 degrees, which corrected to a mean of 33.3 after operative fixation but decreased to a mean of 28.1 at the time of the final follow-up. The mean Bohler angle was 32.3 on the contralateral uninjured side. The mean MFA score was 16.5 (range, 1-34). There were no wound infections or subtalar arthrodesis procedures performed. CONCLUSIONS: ORIF by a lateral extensile approach is a safe and viable option for patients presenting in a delayed fashion with a displaced intraarticular calcaneus fracture. Marked improvement in the Bohler angle, acceptable functional outcome, and low complication rates can be expected when surgery is performed by an experienced surgeon. LEVEL OF EVIDENCE: Level IV. See Instructions for Authors for a complete description of levels of evidence.

Management of Lateral Thigh Pain following Cephalomedullary Nail: A Technical Note.

Peritrochanteric hip fractures are most commonly treated with proximal femoral fixation devices, such as a cephalomedullary nail or sliding hip screw. As usage rates increase for these fixation devices, complications from their insertion are becoming more prevalent. Lateral hip pain from proximal locking device insertion and prominence continues to be one of the most frequent complaints regarding hardware irritation following this surgical procedure. Conservative treatment options for this complaint include local corticosteroid injection and physical therapy, although once these treatments have been exhausted, surgical intervention may be recommended. This has generally been managed previously with implant removal, although studies have shown associated femoral neck fractures after removal even with the prescribed protected postoperative weight bearing. Additionally, in certain situations (e.g., when the nail is placed for prophylactic treatment), its removal is contraindicated. The purpose of this manuscript is to describe an alternative treatment option that would limit morbidity, and the need for proximal locking device or implant removal by excising the portion of the iliotibial band causing hip irritation at the level of the proximal locking device, while leaving the retained implant in place. This surgical option would allow most patients to return to their pre-operative weight-bearing status immediately following surgery without the need for additional postoperative precautions.

High-Energy Pilon Fractures: Role of External Fixation in Acute and Definitive Treatment. What are the Indications and Technique for Primary Ankle Arthrodesis?

External fixation is an essential tool in the management of high-energy pilon fractures. Reduction techniques using the external fixator and fixation constructs for use with external fixation as a part of stage management are reviewed. The concepts of external fixation with limited articular fixation is discussed. The use of circular external fixation in both acute management of high-energy pilon fractures, as well as the indications and technique for acute ankle arthrodesis as part of primary treatment of pilon fractures are outlined.

Recombinant Human Platelet-Derived Growth Factor BB in Combination With a Beta-Tricalcium Phosphate (rhPDGF-BB/ß-TCP)-Collagen Matrix as an Alternative to Autograft.

BACKGROUND: Joint arthrodesis often employs autograft to promote union; graft harvesting can lead to perioperative morbidity. A Canadian randomized controlled trial (RCT) demonstrated that recombinant human platelet-derived growth factor BB homodimer (rhPDGF-BB) combined with beta-tricalcium phosphate (ß-TCP)-collagen was a safe, effective alternative to autograft. This multicenter North American RCT compared the safety and efficacy of rhPDGF-BB/ß-TCP-collagen with autograft for ankle and hindfoot fusion. Subclassification using propensity scores (PS) incorporated patients from previous trials for enhanced statistical power for noninferiority testing and broader review of treatments. METHODS: Patients requiring ankle or hindfoot arthrodesis and supplemental bone graft were treated with rhPDGF-BB/ß-TCP-collagen (n = 69) or autograft (n = 35). Outcomes included joint fusion on computed tomography (24 weeks), clinical healing status, visual analog scale (VAS) pain, Short-Form 12 (SF-12), American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale, and Foot Function Index (FFI) scores over 52 weeks. PS methodology addressed potential selection bias arising from pooling data among these patients and 2 previous RCTs with similar inclusion criteria, surgical techniques, graft harvest techniques, and outcomes. All 132 rhPDGF-BB/ß-TCP-collagen-treated patients and 167 of 189 candidate autograft-treated controls were selected for comparison by an independent statistician blinded to outcomes. RESULTS: In the PS subclassification, 68.1% treatment patients and 68.4% controls achieved >50% osseous bridging at fusion sites. Clinical healing status was achieved in 84.8% of treated patients and 90.7% of controls at 52 weeks. Clinical, functional, and quality of life results demonstrated noninferiority of rhPDGF-BB/ß-TCP-collagen to autograft. Safety-related outcomes were equivalent. CONCLUSION: PS subclassification analysis of 3 RCTs demonstrated that rhPDGF-BB/ß-TCP-collagen was as effective as autograft for ankle and hindfoot fusions, with less pain and morbidity than treatment with autograft. LEVEL OF EVIDENCE: Level I, prospective randomized study.

Managing the open calcaneal fracture: A systematic review.

INTRODUCTION: Open fractures of the calcaneus are rare. They are mostly caused by high-energy trauma. There are several treatment options for calcaneal fractures. However, treatment of open calcaneal fractures might need a different approach, as open calcaneal fractures are associated with high rates of complications. The purpose of this study was to provide a literature overview on the management of open calcaneal fractures, and deduct a more standardized treatment algorithm. MATERIAL AND METHODS: A literature review was conducted in the databases of PubMed, EMBASE and the Cochrane Library for articles describing the management of open calcaneal fractures. Excluded were studies with less than 10 patients, studies describing combat injuries and reviews. Only articles published from 1998 to 2017 were included and there were no language restrictions. RESULTS: A total of 18 articles were included with 616 open calcaneal fractures in 598 patients. Most wounds were Gustilo grade III and most fractures were Sanders type III. Definitive surgery was performed after a mean of 9.8days and in most cases in the form of ORIF via ELA. The complication rate was 21% and the mean AOFAS score was 73.7 points. CONCLUSION: The complication rates of open calcaneal fractures are high and increase with the severity of the wound. A treatment algorithm is suggested. However, to produce a more evidence-based protocol and achieve consensus for treatment, additional research should be done, preferably in the form of a prospective multicenter database.

Acute and Chronic Syndesmotic Injury: The Authors' Approach to Treatment.

Ankle injuries are a common traumatic injury. Rupture to the syndesmosis may occur as a result of these injuries. Strategies for the treatment of both acute and chronic syndesmotic repair are reviewed in detail. Significance of Chaput, Wagstaffe, and posterior malleolus fractures on syndesmotic stability are reviewed. Treatment considerations for total ankle arthroplasty are discussed, and correction of coronal plane deformity as a result of late syndesmotic injury at the time of ankle arthroplasty is outlined.

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.

Calcaneal Fractures - Should We or Should We not Operate?

The best treatment for displaced, intraarticular fractures of the calcaneum remains controversial. Surgical treatment of these injuries is challenging and have a considerable learning curve. Studies comparing operative with nonoperative treatment including randomized trials and meta-analyses are fraught with a considerable number of confounders including highly variable fracture patterns, soft-tissue conditions, patient characteristics, surgeon experience, limited sensitivity of outcome measures, and rehabilitation protocols. It has become apparent that there is no single treatment that is suitable for all calcaneal fractures. Treatment should be tailored to the individual fracture pathoanatomy, accompanying soft-tissue damage, associated injuries, functional demand, and comorbidities of the patient. If operative treatment is chosen, reconstruction of the overall shape of the calcaneum and joint surfaces are of utmost importance to obtain a good functional result. Despite meticulous reconstruction, primary cartilage damage due to the impact at the time of injury may lead to posttraumatic subtalar arthritis. Even if subtalar fusion becomes necessary, patients benefit from primary anatomical reconstruction of the hindfoot geometry because in situ fusion is easier to perform and associated with better results than corrective fusion for hindfoot deformities in malunited calcaneal fractures. To minimize wound healing problems and stiffness due to scar formation after open reduction and internal fixation (ORIF) through extensile approaches several percutaneous and less invasive procedures through a direct approach over the sinus tarsi have successfully lowered the rates of infections and wound complications while ensuring exact anatomic reduction. There is evidence from multiple studies that malunited displaced calcaneal fractures result in painful arthritis and disabling, three-dimensional foot deformities for the affected patients. The poorest treatment results are reported after open surgical treatment that failed to achieve anatomic reconstruction of the calcaneum and its joints, thus combining the disadvantages of operative and nonoperative treatment. The crucial question, therefore, is not only whether to operate or not but also when and how to operate on calcaneal fractures if surgery is decided.

Plate Fixation of Talus Fractures: Where, When, and How?

Talus fractures are rare orthopedic injuries. Surgical fixation is challenging for treating surgeons. The clear majority of fractures require operative treatment. The indication and use of plates in fixation of talus fractures are reviewed. Specific applications including fractures of the lateral process, posterior fractures, extreme comminution, bone grafting, and spring plating to hold key segments are reviewed in this article.

Surgical Treatment of Posteromedial Talus Fractures: Technique Description and Results of 10 Cases.

BACKGROUND: The aim of this study is to describe a surgical technique for successful treatment of posteromedial talar body fractures and establish treatment recommendations for fractures of the posterior aspect of the talus. MATERIALS AND METHODS: Ten patients treated operatively for a posteromedial talar body fractures entering both the subtalar and ankle articulations with a minimum of 1-year followup were identified from a trauma database. Age, mechanism of injury, associated injuries, time to surgery, complications, the range of motion, secondary procedures, and need for arthrodesis were evaluated. RESULTS: Followup averaged 4.8 years (1-10). Eight of ten patients had high-energy mechanisms of injury. Six patients had associated medial subtalar dislocations with two open. Associated injuries were common. No surgical complications occurred. The range of motion was present but decreased. No arthrodesis procedures were performed. CONCLUSIONS: Operative fixation of posteromedial talus fractures with the described surgical technique resulted in acceptable outcomes in this series of patients with improved outcomes when compared to prior reports in the literature.

Treatment of Peripheral Talus Fractures.

Peripheral talus fractures include injuries to the lateral process, posteromedial talar body, and talar head. These injuries are rare and are often missed. Nonunion with conservative treatment is high and excision can lead to joint instability, rapid arthrosis, and earlier need for arthrodesis. Open reduction internal fixation of most peripheral talus fractures is critical to achieving a good outcome. Open reduction leads to more rapid union and ability to mobilize the ankle and subtalar joints, quicker revascularization of the talus, and lower rates of arthrosis. Surgical treatment can lead to substantial functional improvement and a slowing of the degenerative process.