Polymethylmethacrylate (PMMA) Augmentation Enhances the Mechanical Characteristics of Midfoot Beam Constructs in Charcot Neuroarthropathy Cadaver Model.

BACKGROUND: Even with the best conservative care, patients with Charcot neuroarthropathy (CN) of the foot and ankle often ulcerate, increasing their risk of infection, amputation, and death. Surgical fixation has been associated with risk of recurrent ulceration, potentially due to poor bone quality prone to recurrent deformity and ulceration. We propose midfoot beam reconstruction with PMMA augmentation as a novel means of improving fixation. METHODS: A protocol was developed to create characteristic CN midfoot fragmentation both visually and fluoroscopically in each of 12 matched-pair cadaveric feet. Afterward, the pairs were divided into 2 groups: (1) midfoot beam fusion surgery alone, and (2) midfoot beam fusion surgery augmented with PMMA. A solid 7.0-mm beam was placed into the medial column and a solid 5.5-mm beam was placed across the lateral column. In the PMMA group, 8 to 10 mL of PMMA was inserted into the medial column. The hindfoot of each specimen was potted and the metatarsal heads were cyclically loaded for 1800 cycles, followed by load to failure while load and displacement were continually recorded. RESULTS: One specimen in the beam alone group failed before reaching the 1800th cycle and was not included in the failure analysis. The midfoot beam only group demonstrated greater mean displacement during cycle testing compared with the PMMA group, P < .05. The maximum force (N), stiffness (N/mm), and toughness (Nmm) were all significantly greater in the group augmented with PMMA, P < .05. CONCLUSION: In a CN cadaveric model, PMMA augmentation significantly decreased gapping during cyclic loading and nearly doubled the load to failure compared with midfoot beams alone. CLINICAL RELEVANCE: The results of this biomechanical study demonstrate that augmentation of midfoot beams with PMMA increases the strength and stiffness of the fusion construct. This increased mechanical toughness may help reduce the risk of nonunion and infection in patients with neuropathic midfoot collapse.

Republication of "Preliminary Experience Using Bioactive Glass Wedges for Cotton Osteotomy".

Background: Medial cuneiform dorsal opening wedge (Cotton) osteotomy is often used for treating forefoot varus in patients undergoing surgery for stage II posterior tibialis tendon dysfunction. The goal of this study was to examine the radiographic outcomes of Cotton osteotomy with bioactive glass wedge to assess for both maintenance of correction and clinical results and complications. We hypothesized that bioactive glass wedges would maintain correction of the osteotomy with low complication rates. Methods: Between December 2015 and June 2016, the charts of 17 patients (10 female and 7 male) who underwent Cotton osteotomy using bioactive glass wedges were retrospectively reviewed. Patient age averaged 56.8 years (range, 16-84). The average follow-up was 6.5 months. Radiographs were reviewed to assess for initial correction and maintenance of correction of medial column sag as well as for union. Charts were reviewed for complications. Results: The medial column sag correction averaged 15.6% on the final postoperative lateral radiograph. Meary angle averaged 19 degrees (3.14-42.8 degrees) preoperatively and 5.5 degrees (0.4-20.7 degrees) at final follow-up. All patients achieved clinical and radiographic union. One patient developed neuropathic midfoot pain and was managed with sympathetic blocks. One patient had a delayed union that healed at 6 months without surgical intervention. No patients required the use of custom orthotics or subsequent surgical procedures. Conclusion: Cotton osteotomy with bioactive glass wedges produced consistent correction of the medial column with low risk. Level of Evidence: Level IV, case series.

Accuracy of Pain Tolerance Self-assessment Versus Objective Pressure Sensitivity.

INTRODUCTION: Effective treatment of postoperative pain after elective surgery remains elusive, and the experience of pain can be variable for patients. The patient's intrinsic pain tolerance may contribute to this variability. We sought to identify whether there was a correlation between subjective report of intrinsic pain tolerance and objective measurement of pressure dolorimetry (PD). We also sought to identify whether a correlation existed between PD and Patient Reported Outcome Measurement Information System (PROMIS) scores of pain intensity, physical function, and mood. PD is a validated, objective method to assess pain tolerance. Markers of general mental and physical health are correlated with pain sensitization and may also be linked to pain tolerance. METHODS: PROMIS scores, dolorimetry measurements, and survey data were collected on 40 consecutive orthopaedic foot and ankle surgery patients at the initial clinic visit. Patients were included if they had normal sensation on the plantar foot and no prior surgery or plantar heel source of pain. RESULTS: Objective dolorimetry data reflecting 5/10 pain for the patients were 24 N/cm 2 (±8.9). Patients estimated their pain threshold as 7.3/10 (±2.1). No correlation was found between objective and subjective pain threshold identified. A moderate negative correlation of R = -0.44 was observed regarding PROMIS-M with dolorimetry data ( P < -0.05). PROMIS-M score >60 had a significant decrease in pain threshold to 15.9 ± 8.5 N/cm 2 compared with 25.7 ± 8.9 N/cm 2 for those who were less depressed with a PROMIS<60 ( P < 0.05). CONCLUSION: Subjective pain tolerance is not correlated with the patient's own objective pain threshold or markers of mental health and should not be used to assist clinical decision making. PROMIS-M is inversely correlated with objective pain. Higher PROMIS-M scores are associated with a lower objective pain threshold. LEVEL OF EVIDENCE: Level II-Lesser Quality Randomized Controlled Trial or Prospective Comparative Study.

Evaluation and Management of Adult Footdrop.

Footdrop is a common musculoskeletal condition defined by weakness in ankle joint dorsiflexion. Although the etiology varies, footdrop is characterized by specific clinical and gait abnormalities used by the patient to overcome the loss of active ankle dorsiflexion. The condition is often associated with deformity because soft-tissue structures may become contracted if not addressed. Patients may require the use of special braces or need surgical treatment to address the notable level of physical dysfunction. Surgical treatment involving deformity correction to recreate a plantigrade foot along with tendon transfers has been used with notable success to restore a near-normal gait. However, limitations and postoperative dorsiflexion weakness have prompted investigation in nerve transfer as a possible alternative surgical treatment.

Return to Sport Following Operative Treatment of Displaced Medial Sesamoid Fractures in NCAA Division I Football Players.

Level of Evidence: Level V.

The Ischemic toe following forefoot surgery: A review of current practices and a proposed approach for management.

Toe hypoperfusion is a commonly encountered concern following forefoot surgery, yet there is limited clinical guidance available to surgeons to aid in management of this scenario. This work aims to review the etiology, pathophysiology and current strategies to address a perioperative ischemic toe. The authors review various interventions to approach this problem based on available evidence and clinical experience. Interventions to restore perfusion can be loosely based on the ischemic causality they intend to address. Described maneuvers to restore perfusion have, in turn, been designed to either chemically (through topical/local medication) or mechanically (bending/removing K-wires, adjusting repair tension) aid in mitigation of the offending cause. Depending upon the type of surgery performed, which may or may not include instrumentation, a surgeon can implement a series of steps to maximize restoration of toe perfusion. LEVEL OF EVIDENCE: V.

Dexamethasone Addition to Popliteal Nerve Blocks: Effects on Duration of Analgesia and Incidence of Postoperative Nerve Complication.

Background. The purpose of this prospective, double-blinded randomized control pilot study was to evaluate the effect of adjunctive dexamethasone on analgesia duration and the incidence of postoperative neuropathic complication. Peripheral nerve blocks are an effective adjunct to decrease postoperative pain in foot and ankle surgery, and any possible modalities to augment their efficacy is of clinical utility. Methods. Patients were randomly assigned to a control group (n = 25) receiving nerve blocks of bupivacaine and epinephrine or an experimental group (n = 24) with an adjunctive 8 mg dexamethasone. The patients, surgeons, and anesthesiologists were all blinded to allocation. Patients had a minimum 1 year postoperative follow-up. Results. Forty-nine patients completed the protocol. There was no statistically significant difference in analgesia duration (P = .38) or postoperative neuropathic complication incidence (P = .67) between the 2 groups. Conclusions. The addition of dexamethasone to popliteal nerve blocks does not appear to affect analgesia duration or incidence of postoperative neuropathic complications. However, our study was underpowered, and we recommend a larger scale prospective study for validation.Levels of Evidence: Level II: Prospective, randomized control pilot study.

Career Outlook and Performance of Professional Athletes After Achilles Tendon Rupture: A Systematic Review.

BACKGROUND: The purpose of this systematic review is to examine the literature on Achilles tendon (AT) injuries in professional athletes to determine their rate of return to play (RTP), performance, and career outcome after AT rupture. METHODS: A literature search of MEDLINE, Google Scholar, CINAHL, and Cochrane Library databases was performed. Included studies reported outcomes related to RTP (time and rate), durability and player participation, and player performance following AT rupture in professional athletes of the National Football League (NFL), National Basketball Association (NBA), Major League Baseball (MLB), and professional soccer leagues. RESULTS: Fifteen studies met inclusion criteria for analysis. Athletes were able to return to professional sport participation 76% of the time, with mean time to RTP of 11 months following AT injury. Athletes experienced a decline in player efficiency ratings, power ratings, and sport- and position-specific statistics in the NFL, NBA, and professional soccer leagues compared to noninjured controls. RTP rate was significantly lower following AT rupture in comparison to athletes sustaining other common orthopedic injuries such as anterior cruciate ligament injuries, meniscal tears, and ankle fractures in both NFL and NBA athletes. CONCLUSION: AT rupture prohibits nearly 25% of professional athletes from returning to their respective sport. Of those able to return to compete at a professional level, the mean time to RTP is 11 months-nearly double the estimated 6-month recovery for RTP in the general population. Furthermore, player performance and durability were curtailed following AT rupture. This review of the literature should be used to set evidence-based goals and establish realistic expectations for RTP for elite athletes following AT injuries. LEVEL OF EVIDENCE: Level III, systematic review.

Titrating the Amount of Bony Correction in Progressive Collapsing Foot Deformity.

RECOMMENDATION: There is evidence indicating that the amount of bony correction performed in the setting of progressive collapsing foot deformity reconstructive surgery can be titrated within a recommended range for a variety of procedures. The typical range when performing a medial displacement calcaneal osteotomy should be 7 to 15 mm of medialization of the tuberosity. The typical range when performing an Evans lateral column lengthening should be 5 to 10 mm of a laterally based wedge in the anterior calcaneus. The typical range when performing a plantarflexion opening wedge osteotomy of the medial cuneiform (Cotton) osteotomy should be 5 to 10 mm of a dorsal wedge. LEVEL OF EVIDENCE: Level V, consensus, expert opinion.

Progressive Collapsing Foot Deformity: Consensus on Goals for Operative Correction.

RECOMMENDATION: In the treatment of progressive collapsing foot deformity (PCFD), the combination of bone shape, soft tissue failure, and host factors create a complex algorithm that may confound choices for operative treatment. Realignment and balancing are primary goals. There was consensus that preservation of joint motion is preferred when possible. This choice needs to be balanced with the need for performing joint-sacrificing procedures such as fusions to obtain and maintain correction. In addition, a patient's age and health status such as body mass index is important to consider. Although preservation of motion is important, it is secondary to a stable and properly aligned foot. LEVEL OF EVIDENCE: Level V, consensus, expert opinion.

Consensus on Indications for Isolated Subtalar Joint Fusion and Naviculocuneiform Fusions for Progressive Collapsing Foot Deformity.

RECOMMENDATION: Peritalar subluxation represents an important hindfoot component of progressive collapsing foot deformity, which can be associated with a breakdown of the medial longitudinal arch. It results in a complex 3-dimensional deformity with varying degrees of hindfoot valgus, forefoot abduction, and pronation. Loss of peritalar stability allows the talus to rotate and translate on the calcaneal and navicular bone surfaces, typically moving medially and anteriorly, which may result in sinus tarsi and subfibular impingement. The onset of degenerative disease can manifest with stiffening of the subtalar (ST) joint and subsequent fixed and possibly arthritic deformity. While ST joint fusion may permit repositioning and stabilization of the talus on top of the calcaneus, it may not fully correct forefoot abduction and it does not correct forefoot varus. Such varus may be addressed by a talonavicular (TN) fusion or a plantar flexion osteotomy of the first ray, but, if too pronounced, it may be more effectively corrected with a naviculocuneiform (NC) fusion. The NC joint has a curvature in the sagittal plane. Thus, preserving the shape of the joint is the key to permitting plantarflexion correction by rotating the midfoot along the debrided surfaces and to fix it. Intraoperatively, care must be also taken to not overcorrect the talocalcaneal angle in the horizontal plane during the ST fusion (eg, to exceed the external rotation of the talus and inadvertently put the midfoot in a supinated position). Such overcorrection can lead to lateral column overload with persistent lateral midfoot pain and discomfort. A contraindication for an isolated ST fusion may be a rupture of posterior tibial tendon because of the resultant loss of the internal rotation force at the TN joint. In these cases, a flexor digitorum longus tendon transfer is added to the procedure. LEVEL OF EVIDENCE: Level V, consensus, expert opinion.

Indications for Deltoid and Spring Ligament Reconstruction in Progressive Collapsing Foot Deformity.

RECOMMENDATION: There is evidence supporting medial soft tissue reconstruction, such as spring and deltoid ligament reconstructions, in the treatment of severe progressive collapsing foot deformity (PCFD). We recommend spring ligament reconstruction to be considered in addition to lateral column lengthening or subtalar fusion at the initial operation when those procedures have given at least 50% correction but inadequate correction of the severe flexible subluxation of the talonavicular and subtalar joints. We also recommend combined flatfoot reconstruction and deltoid reconstruction be considered as a joint sparing alternative in the presence of PCFD with valgus deformity of the ankle joint if there is 50% or more of the lateral joint space remaining. LEVEL OF EVIDENCE: Level V, expert opinion.

Consensus for the Indication of Lateral Column Lengthening in the Treatment of Progressive Collapsing Foot Deformity.

RECOMMENDATION: Progressive collapsing foot deformity (PCFD) is a complex 3D deformity with varying degrees of hindfoot valgus, forefoot abduction, and midfoot supination. Although a medial displacement calcaneal osteotomy can correct heel valgus, it has far less ability to correct forefoot abduction. More severe forefoot abduction, most frequently measured preoperatively by assessing talonavicular coverage on an anteroposterior (AP) weightbearing conventional radiographic view of the foot, can be more effectively corrected with a lateral column lengthening procedure than by other osteotomies in the foot. Care must be taken intraoperatively to not overcorrect the deformity by restricting passive eversion of the subtalar joint or causing adduction at the talonavicular joint on simulated AP weightbearing fluoroscopic imaging. Overcorrection can lead to lateral column overload with persistent lateral midfoot pain. The typical amount of lengthening of the lateral column is between 5 and 10 mm. LEVEL OF EVIDENCE: Level V, consensus, expert opinion. CONSENSUS STATEMENT ONE: Lateral column lengthening (LCL) procedure is recommended when the amount of talonavicular joint uncoverage is above 40%. The amount of lengthening needed in the lateral column should be judged intraoperatively by the amount of correction of the uncoverage and by adequate residual passive eversion range of motion of the subtalar joint.Delegate vote: agree, 78% (7/9); disagree, 11% (1/9); abstain, 11% (1/9).(Strong consensus). CONSENSUS STATEMENT TWO: When titrating the amount of correction of abduction deformity intraoperatively, the presence of adduction at the talonavicular joint on simulated weightbearing fluoroscopic imaging is an important sign of hypercorrection and higher risk for lateral column overload.Delegate vote: agree, 100% (9/9); disagree, 0%; abstain, 0%.(Unanimous, strongest consensus). CONSENSUS STATEMENT THREE: The typical range for performing a lateral column lengthening is between 5 and 10 mm to achieve an adequate amount of talonavicular coverage.Delegate vote: agree, 100% (9/9); disagree, 0%; abstain, 0%.(Unanimous, strongest consensus).

Consensus for the Use of Weightbearing CT in the Assessment of Progressive Collapsing Foot Deformity.

RECOMMENDATION: There is evidence that the use of WEIGHTBEARING imaging aids in the assessment of progressive collapsing foot deformity (PCFD). The following WEIGHTBEARING conventional radiographs (CRs) are necessary in the assessment of PCFD patients: anteroposterior (AP) foot, AP or mortise ankle, and lateral foot. If available, a hindfoot alignment view is strongly recommended. If available, WEIGHTBEARING computed tomography (CT) is strongly recommended for surgical planning. When WEIGHTBEARING CT is obtained, important findings to be assessed are sinus tarsi impingement, subfibular impingement, increased valgus inclination of the posterior facet of the subtalar joint, and subluxation of the subtalar joint at the posterior and/or middle facet. LEVEL OF EVIDENCE: Level V, consensus, expert opinion.

Consensus for the Indication of a Medializing Displacement Calcaneal Osteotomy in the Treatment of Progressive Collapsing Foot Deformity.

RECOMMENDATION: There is evidence that the medial displacement calcaneal osteotomy (MDCO) can be effective in treating the progressive collapsing foot deformity (PCFD). This juxta-articular osteotomy of the tuberosity shifts the mechanical axis of the calcaneus from a more lateral position to a more medial position, which provides mechanical advantage in the reconstruction for this condition. This also shifts the action of the Achilles tendon medially, which minimizes the everting deforming effect and improves the inversion forces. When isolated hindfoot valgus exists with adequate talonavicular joint coverage (less than 35%-40% uncoverage) and a lack of significant forefoot supination, varus, or abduction, we recommend performing this osteotomy as an isolated bony procedure, with or without additional soft tissue procedures. The clinical goal of the hindfoot valgus correction is to achieve a clinically neutral heel, as defined by a vertical axis from the heel up the longitudinal axis of the Achilles tendon and distal aspect of the leg. The typical range when performing a MDCO, while considering the location and rotation of the osteotomy, is 7 to 15 mm of correction. LEVEL OF EVIDENCE: Level V, consensus, expert opinion.

Classification and Nomenclature: Progressive Collapsing Foot Deformity.

RECOMMENDATION: The historical nomenclature for the adult acquired flatfoot deformity (AAFD) is confusing, at times called posterior tibial tendon dysfunction (PTTD), the adult flexible flatfoot deformity, posterior tibial tendon rupture, peritalar instability and peritalar subluxation (PTS), and progressive talipes equinovalgus. Many but not all of these deformities are associated with a rupture of the posterior tibial tendon (PTT), and some of these are associated with deformities either primarily or secondarily in the midfoot or ankle. There is similar inconsistency with the use of classification schemata for these deformities, and from the first introduced by Johnson and Strom (1989), and then modified by Myerson (1997), there have been many attempts to provide a more comprehensive classification system. However, although these newer more complete classification systems have addressed some of the anatomic variations of deformities encountered, none of the above have ever been validated. The proposed system better incorporates the most recent data and understanding of the condition and better allows for standardization of reporting. In light of this information, the consensus group proposes the adoption of the nomenclature "Progressive Collapsing Foot Deformity" (PCFD) and a new classification system aiming at summarizing recent data published on the subject and to standardize data reporting regarding this complex 3-dimensional deformity. LEVEL OF EVIDENCE: Level V, consensus, expert opinion. CONSENSUS STATEMENTS VOTED: CONSENSUS STATEMENT ONE: We will rename the condition to Progressive Collapsing Foot Deformity (PCFD), a complex 3-dimensional deformity with varying degrees of hindfoot valgus, forefoot abduction, and midfoot varus.Delegate vote: agree, 100% (9/9); disagree, 0%; abstain, 0%.(Unanimous, strongest consensus)CONSENSUS STATEMENT TWO: Our current classification systems are incomplete or outdated.Delegate vote: agree, 100% (9/9); disagree, 0%; abstain, 0%.(Unanimous, strongest consensus)CONSENSUS STATEMENT THREE: MRI findings should be part of a new classification system.Delegate vote: agree, 33% (3/9); disagree, 67% (6/9); abstain, 0%.(Weak negative consensus)CONSENSUS STATEMENT FOUR: Weightbearing CT (WBCT) findings should be part of a new classification system.Delegate vote: agree, 56% (5/9); disagree, 44% (4/9); abstain, 0%.(Weak consensus)CONSENSUS STATEMENT FIVE: A new classification system is proposed and should be used to stage the deformity clinically and to define treatment.Delegate vote: agree, 89% (8/9); abstain, 11% (1/9).(Strong consensus).

Consensus on Indications for Medial Cuneiform Opening Wedge (Cotton) Osteotomy in the Treatment of Progressive Collapsing Foot Deformity.

RECOMMENDATION: Forefoot varus is a physical and radiographic examination finding associated with the Progressive Collapsing Foot Deformity (PCFD). Varus position of the forefoot relative to the hindfoot is caused by medial midfoot collapse with apex plantar angulation of the medial column. Some surgeons use the term forefoot supination to describe this same deformity (see Introduction section with nomenclature). Correction of this deformity is important to restore the weightbearing tripod of the foot and help resist a recurrence of foot collapse. When the forefoot varus deformity is isolated to the medial metatarsal and medial cuneiform, correction is indicated with an opening wedge medial cuneiform (Cotton) osteotomy, typically with interposition of an allograft bone wedge from 5 to 11 mm in width at the base. When the forefoot varus is global, involving varus angulation of the entire forefoot and midfoot relative to the hindfoot, other procedures are needed to adequately correct the deformity. LEVEL OF EVIDENCE: Level V, consensus, expert opinion.

Return to Sports and Activity After Total Ankle Arthroplasty and Arthrodesis: A Systematic Review.

BACKGROUND: There is no consensus regarding participation in sports and recreational activities following total ankle replacement (TAR) and ankle arthrodesis (AA). This systematic review summarizes the evidence on return to sports and activity after operative management with either TAR or AA for ankle osteoarthritis (OA). METHODS: A literature search of MEDLINE, EMBASE, CINAHL, and Cochrane Library databases was performed. Risk of bias of included studies was assessed using Methodological Index for Non-Randomized Studies (MINORS) criteria. Included studies reported sport and activity outcomes in patients undergoing TAR and AA, with primary outcomes being the percentage of sports participation and level of sports participation. RESULTS: Twelve studies met inclusion criteria for analysis. There were 1270 ankle procedures, of which 923 TAR and 347 AA were performed. The mean reported patient age was 59.2 years and the mean BMI was 28 kg/m2. The mean follow-up was 43 months. Fifty-four percent of patients were active in sports preoperatively compared with 63.7% postoperatively. The mean preoperative activity participation rate was 41% in the TAR cohort, but it improved to 59% after TAR, whereas the preoperative activity participation rate of 73% was similar to the postoperative rate of 70% in the AA cohort. The most common sports in the TAR and AA groups were swimming, hiking, cycling, and skiing. CONCLUSION: Participation in sports activity was nearly 10% improved after operative management of ankle OA with TAR and remains high after AA. The existing literature demonstrated a large improvement in pre- to postoperative activity levels after TAR, with minimal change in activity after AA; however, AA patients were more active at baseline. The most frequent postoperative sports activities after operative management of ankle OA were swimming, hiking, cycling, and skiing. Participation in high-impact sports such as tennis, soccer, and running was consistently limited after surgery. This review of the literature will allow patients and foot and ankle surgeons to set evidence-based goals and establish realistic expectations for postoperative physical activity after TAR and AA. LEVEL OF EVIDENCE: Level III, systematic review.