Isolated Talonavicular Arthrodesis as Treatment for Flexible Progressive Collapsing Foot Deformity: A Case Series.

Background: For the younger, more active patient with flexible symptomatic progressive collapsing foot deformity (PCFD), joint-sparing procedures may be preferred to preserve functional motion. Isolated talonavicular (TN) arthrodesis has been described for treatment of rigid and flexible PCFD for patients that are older and less active whose deformity is still correctable through the TN joint. The purpose of this study was to evaluate radiographic and clinical outcomes in patients with PCFD treated with isolated triplanar correction with a TN joint arthrodesis. Methods: Forty-nine patients (53 feet) with flexible PCFD underwent isolated TN arthrodesis. Weightbearing radiographs were performed pre- and postoperatively, and measurements included lateral talar-first metatarsal angle, calcaneal pitch, TN coverage angle, and the anteroposterior (AP) talar-first metatarsal angle. The Foot and Ankle Ability Measure (FAAM) and Veterans-Rand 12-Item Health Survey (VR-12) scores were also collected. Results: Thirty-five females and 14 males were evaluated with a mean age of 63 years, at an average follow-up of 41.3 months. Significant improvements were found radiographically. Lateral radiographs demonstrated improvements in lateral talar-first metatarsal angle from 25.2 degrees preoperatively to 9.5 degrees postoperatively (P < .001) and calcaneal pitch from 14.9 degrees preoperatively to 17.5 degrees postoperatively (P < .001). AP radiographs showed the TN coverage angle improving from 35.0 degrees to 4.9 degrees postoperatively (P < .001) and AP talar-first metatarsal angle improving from 17.3 degrees to 5.9 degrees postoperatively (P < .001). Clinical outcomes were improved in the FAAM pain score (48.6 to 39.2, P = .130), FAAM ADL score (53.8 to 69.2, P = .002), FAAM Sport score (29.5 to 40.7, P = .099), and the overall FAAM score (47.7 to 63.1, P = .006). Patient satisfaction with medical care was 85.2/100 postoperatively. Conclusion: Isolated TN arthrodesis is a viable surgical option for older, lower-demand patients with flexible PCFD. This study demonstrated significant improvements in radiographic alignment and FAAM scores. Comparative studies with other surgical procedures should be performed to determine which is the best technique for older, lower-demand patients with flexible PCFD. Level of Evidence: Level III, retrospective cohort study.

Patient-Reported Outcomes and Early Complications After Synthetic Cartilage Device Implantation.

BACKGROUND: Previous Level I studies show promising results for the use of a hydrogel synthetic cartilage implant (SCI) for the treatment of hallux rigidus. A recent independent retrospective review has put those results into question, however. The purpose of this article is to report patient-reported outcomes and early complications using this implant so as to add to the paucity of data in the literature regarding this implant. METHODS: This was a retrospective chart review of patients undergoing hydrogel synthetic cartilage implant for the treatment of hallux rigidus from July 2017 to November 2018. Data collected included patient demographics, radiographic grading, and outcomes: Veterans Rand 12 Item Health Survey (VR-12), Foot and Ankle Ability Measure (FAAM), visual analog scale (VAS), patient satisfaction, and complications. Fifty-four patients (59 feet) with an average age of 57.6 (range, 39-78) years were analyzed. The average latest follow-up was 18.9 (range, 3-31.3) months. Body mass index was 26.7 (range, 18.7-35.2). None were diabetic and 5 were smokers. RESULTS: The mean outcome improvements were 6.5 points (VR-12 Physical), 17.2 points (FAAM ADL), 27.4 points (FAAM Sport), and 18.4 points (VAS) (P < .01 for each). Scores were significantly improved from preoperatively to most recent follow-up for FAAM ADL (71.0 vs 88.2 points), FAAM Sports (44.6 vs 72.0 points), and VAS (49.4 vs 31.0) (P < .01). Overall, 72.5% patients would definitely or probably have the operation again. Ten patients (18.5%) went on to have revision surgery. Of these, 7 patients were revised to an arthrodesis, and 1 metal hemiarthroplasty and 2 implants were removed because of infection. CONCLUSION: Synthetic cartilage implantation for the treatment of hallux rigidus demonstrated improved pain and outcome scores at short-term follow-up. Reoperation and conversion to fusion rates were comparable to prior studies. LEVEL OF EVIDENCE: Level IV, case series.

Intra-articular Diagnostic Injection Exhibits Poor Predictive Value for Outcome After Hip Arthroscopy.

PURPOSE: To determine whether the amount of pain relief after preoperative intra-articular (IA) anesthetic injection predicts clinical and functional outcomes after hip arthroscopy, especially when controlling for the presence of chondral degeneration. METHODS: We identified patients who underwent IA injection and subsequent hip arthroscopy for labral pathology between 2007 and 2013 performed by a single surgeon. Inclusion criteria were ultrasound- or fluoroscopic-guided IA anesthetic injection performed at our institution, prospectively documented pre- and postinjection numerical rating scale pain scores, and minimum 1-year follow-up postoperatively. Patients were divided into 2 groups, those who received >50% pain relief from preoperative IA anesthetic injection and those who received ≤50% relief. Preoperative radiographs were reviewed, and degree of osteoarthritis was determined using the Tonnis classification system. Outcomes were assessed with Modified Harris Hip Score and Hip Outcome Score (HOS). Univariate and multivariate models were performed to assess whether percent pain relief correlated with outcome. RESULTS: Of the 319 arthroscopic hip surgeries performed between 2007 and 2013, 115 (37%) patients were lost to follow-up, 16 (5%) patients did not receive an IA injection, 16 (5%) patients had an injection containing gadolinium, and 40 (13%) patients completed injections at an outside institution. Five (2%) patients were excluded for a history of ipsilateral hip surgery, and 3 (1%) for a history of contralateral hip surgery, leaving 96 hips in 96 patients. There were 71 females (74%) and 25 males (26%) with a mean age of 37.6 ± 14.0 years. Tonnis was grade 0, 1, and 2 for 26 (27%), 55 (56%), and 16 (17%) patients, respectively. Fifty-one (53%) of the injections contained a corticosteroid. The mean pain relief after IA injection was 73% ± 36% (range, 0% to 100%). Twenty-six hips (26%) had ≤50% pain relief, whereas 70 (73%) had >50% pain relief, and the median time interval from injection to surgery was 3 (range, <1 to 20) months. Outcome scores were obtained at a mean 14.8 (range, 11 to 30) months after arthroscopic surgery. Postoperative mean Modified Harris Hip Score, HOS activities of daily living, and HOS-Sport scores were 79.2 ± 17.3, 82.6 ± 17.3, and 67.4 ± 28.2, respectively. There was no statistical correlation between percent pain relief and outcome. There was no significant difference in outcome scores between those with ≤50% and >50% pain relief. Multivariate regression analysis showed no significant predictors of outcome, including age, gender, Tonnis grade, percent relief with IA injection, or type of surgery. CONCLUSIONS: In this study of patients undergoing hip arthroscopy for labral pathology, our data indicate that the amount of pain relief from IA injection may be a poor predictor of short-term outcome, even when adjusting for chondral degeneration. Although anesthetic injections can be an important diagnostic tool in select patients, a combination of the clinical history, physical examination, and imaging findings is fundamental. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Lateral Tibial Posterior Slope Is Increased in Patients With Early Graft Failure After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: The lateral tibial posterior slope (LTPS) has been reported in multiple studies to correlate with an increased risk for native anterior cruciate ligament (ACL) tearing. To date, no study has examined the effect of an increased LTPS as measured on magnetic resonance imaging (MRI) on the likelihood of ACL graft failure. HYPOTHESIS: An increased LTPS as measured on MRI would correlate with an increased risk for ACL graft failure. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Fifty-eight patients were initially identified who experienced graft failure after primary ACL reconstruction and underwent revision between 1998 and 2009. Exclusion criteria were clinical follow-up of less than 4 years, graft failure occurring greater than 2 years after primary surgery, skeletal immaturity, deep infection, lack of available preoperative MRI, and history of trauma to the proximal tibia. This left 35 patients with early (within 2 years) failure of primary ACL reconstruction. These patients were matched to 35 control participants who had undergone ACL reconstruction with a minimum of 4 years of clinical follow-up and no evidence of graft failure. Patients were matched by age, sex, date of primary surgery, and graft type. The LTPS was then determined on MRI in a blinded fashion. RESULTS: The mean time to failure in patients in the study group was 1 year (range, 0.6-1.4 years). The mean follow-up of those in the matched control group was 6.9 years (range, 4.0-13.9 years). The mean LTPS in the early ACL failure group was found to be 8.4°, which was significantly larger than that in the control group at 6.5° (P = .012). The odds ratio for graft failure considering a 2° increase in the LTPS was 1.6 (95% CI, 1.1-2.2) and continued to increase to 2.4 (95% CI, 1.2-5.0) and 3.8 (95% CI, 1.3-11.3) with 4° and 6° increases in the LTPS, respectively. No significant association was identified between graft type and graft failure. CONCLUSION: An increased LTPS is associated with an increased risk for early ACL graft failure, regardless of graft type. Orthopaedic surgeons should consider measuring the LTPS as part of the preoperative assessment of ACL-injured patients.

Patellar Fracture Following Patellofemoral Arthroplasty.

This study aims to report the incidence of patellar fracture after patellofemoral arthroplasty (PFA) and to determine associated factors as well as outcomes of patients with and without this complication. 77 knees in 59 patients with minimum two-year follow-up were included. Seven (9.1%) patients experienced a patellar fracture at a mean of 34 (range 16-64) months postoperatively. All were treated nonoperatively. Lower BMI (P = 0.03), change in patellar thickness (P < 0.001), amount of bone resected (P = 0.001), and larger trochlear component size (P = 0.01) were associated with a greater incidence of fracture. Fewer fractures occurred when the postoperative patellar height exceeded the preoperatively measured height. No statistically significant differences were found in outcome scores between groups at mean four-year follow-up.

Meniscal tears and articular cartilage damage in the dislocated knee.

PURPOSE: Knee dislocations can cause significant damage to intra-articular knee structures, but currently there are limited data reporting articular cartilage and meniscal injuries in this setting. The purpose of this study is to (1) report the rate of concomitant intra-articular injuries at the time of multiligament reconstruction for knee dislocation, (2) determine whether the pattern of ligament injury is associated with the presence of chondral and meniscal injuries, and (3) assess the relationship between timing of surgery and incidence of chondral and meniscal injuries. METHODS: The records of patients who sustained a knee dislocation between 1992 and 2013 were retrospectively reviewed. Patients included for further review had a PCL-based multiligament knee injury or a minimum of three disrupted ligaments, both indicative of knee dislocation. Patient demographics, ligament injury patterns, meniscal tears and chondral injuries at arthroscopy, and interval from injury to surgery were recorded. Early surgical intervention was defined as <3 months, delayed was between 3 and 12 months, and chronic was >12 months. Data analysis compared ligament injury pattern with chondral and meniscal injuries, as well as the rates of intra-articular injury by timing of surgery. RESULTS: One-hundred and twenty-one patients (122 knees) were included (93 males, 28 females) with a median age at time of surgery of 31 years (range 15-62). Ninety-three knees (76 %) had associated chondral or meniscal injury. Sixty-seven knees (55 %) presented with meniscal tears (26 isolated medial, 27 isolated lateral, and 14 combined medial/lateral), while 52 knees (48 %) had chondral damage, most commonly in the medial compartment. Schenck classification as well as side of injury did not demonstrate consistent relationships with intra-articular injury. A higher incidence of damage to the lateral femoral condyle (20 % vs 3 %; p = 0.02), lateral tibial plateau (20 % vs 2 %; p < 0.01), and patella (40 % vs 13 %; p = 0.01) was found in the chronic group compared to the early group. The chronic group contained significantly more patients with bicompartmental and tricompartmental chondral lesions (25 % vs 6 %; p = 0.03 and 10 % vs 0 %; p = 0.02, respectively). CONCLUSION: Meniscal tears and chondral damage occur frequently in patients with a knee dislocation. A longer interval from injury to surgical reconstruction is associated with higher rates of articular cartilage lesions, especially in multiple compartments. LEVEL OF EVIDENCE: IV.

Does proximal tibial osteotomy with a novel osteotomy system obtain coronal plane correction without affecting tibial slope and patellar height?

PURPOSE: To determine changes in tibial slope, patellar height, and coronal plane alignment after medial opening wedge proximal tibial osteotomy (PTO) using a modern osteotomy system. METHODS: Patients undergoing medial opening wedge PTO for any indication with follow-up until radiographic union were identified. Pre- and post-operative tibial slope (referenced off the anterior tibial cortex, proximal tibial anatomic axis, and posterior tibial cortex), patellar height (Caton-Deschamps, Blackburne-Peel, and Insall-Salvati indices), and coronal plane [mechanical axis and weight-bearing line (WBL) ratio] measurements were taken by two observers and compared. RESULTS: Review of 27 patients demonstrated unchanged tibial slope and slightly decreased patellar height post-operatively (Caton-Deschamps: -0.10 ± 0.09; Blackburne-Peel: -0.11 ± 0.10). Coronal plane measurements showed 6.4° ± 1.8° mean change in mechanical axis. Mean post-operative WBL ratio was significantly lower (51.6 ± 11.5 %) than mean goal WBL ratio (62.2 ± 2.5 %). Preoperative mechanical axis >6° varus and osteoarthritis alone as the surgical indication were risk factors for undercorrection >10 %. CONCLUSIONS: Medial opening wedge PTO using a recently developed instrumentation system was found to have no effect on tibial slope. Patellar height was decreased after osteotomy using this system, although clinical significance of these findings is unknown. Coronal plane undercorrection of 10.6 % of the target WBL ratio was seen in the group as a whole, although secondary analysis of these results indicated that patients with medial compartment osteoarthritis and/or preoperative mechanical axis of >6° varus accounted for the majority of the cases of undercorrection. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Fibular head and tibial-based (2-Tailed) posterolateral corner reconstruction.

Two-tailed techniques for reconstruction of the posterolateral corner use grafts that originate on the femur and insert onto both the proximal tibia and the fibular head. Two-tailed reconstruction aims to reconstruct the fibular collateral ligament, popliteus tendon, and popliteofibular ligament with anatomically placed grafts. This article will review the history, indications, and authors' preferred technique for 2-tailed posterolateral corner reconstruction, as well as biomechanical and clinical outcomes of this technique.

Reconstruction of the posterolateral corner of the knee with achilles tendon allograft.

Posterolateral corner injuries of the knee are relatively rare; however, they can result in significant long-term disability without appropriate treatment. They often occur in the setting of multiligament knee injuries, and as a result, diagnosis and management can be challenging. Severe injuries often require reconstruction, and both anatomic and nonanatomic techniques exist. We describe our preferred operative technique to reconstruct the fibular collateral ligament and posterolateral corner using a single Achilles tendon allograft.

Low frequency of symptomatic venous thromboembolism after multiligamentous knee reconstruction with thromboprophylaxis.

BACKGROUND: Reconstruction of the multiligament-injured knee often involves extended surgical and tourniquet use times and often is performed in patients who have sustained concomitant fractures as well as vascular injuries, all of which would appear to predispose the patient to the potentially serious complications of deep vein thrombosis and perhaps pulmonary embolism, yet little is known about the frequency of venous thromboembolic (VTE) events after multiligamentous knee reconstruction. QUESTIONS/PURPOSES: The purposes of this study were to (1) determine the frequency of symptomatic VTE after multiligamentous knee reconstruction at a single institution; and (2) to determine associated risk factors for VTE in these patients. METHODS: The records of 134 (63% of the 213 consented individuals in our longitudinal database) patients who underwent primary (129 [96%]) or revision (five [4%]) multiligamentous knee reconstruction at a single institution between 1992 and 2013 were retrospectively reviewed. With two patients undergoing procedures bilaterally, this resulted in a total of 136 multiligamentous knee reconstructions. VTE for which clinical symptoms were evident and confirmed by imaging within 3 months after the reconstructive procedure was noted. Pre- and perioperative data were collected with respect to demographics, associated injuries, medical history, smoking status, and surgical data. Standard rehabilitation and thromboprophylaxis protocols were used in all patients. RESULTS: Three cases of symptomatic VTE (three deep vein thromboses) occurred after the 136 reconstructions (2%; 95% confidence interval, 0.53%-7.3%). Two of the three patients were obese and the remaining patient smoked and abused alcohol. However, as a result of a low frequency of VTE, no risk factors could be identified in this series. CONCLUSIONS: Symptomatic VTE occurred in 2% of multiligamentous knee reconstructions at our institution while receiving thromboprophylaxis. This is similar to rates documented after anterior cruciate ligament reconstruction without thromboprophylaxis. Further multicenter research is required to identify the true frequency of and risk factors for developing VTE in patients undergoing multiligamentous knee reconstruction after knee dislocation. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Arthroscopic capsular repair in the treatment of femoroacetabular impingement.

The role of capsular repair in the arthroscopic treatment of femoroacetabular impingement remains poorly defined. Some surgeons rarely repair the capsule, whereas others perform repairs routinely. There is little direct clinical evidence to guide surgeon decision making. When capsular repairs are performed, the procedure requires adequate visualization and careful suture placement either to re-establish the patient's normal capsular volume or to plicate a redundant capsule in a hip with hyperlaxity preoperatively. We present our preferred technique for arthroscopic capsular repair.

A comprehensive five-phase rehabilitation programme after hip arthroscopy for femoroacetabular impingement.

PURPOSE: Recent advancements in the understanding of hip biomechanics have led to the development of techniques to remove bony impingement and repair and/or preserve the labrum during hip arthroscopy. Although much attention in the literature is devoted to diagnosis and treatment, there is little information about post-operative rehabilitation. Therefore, the purpose of this review is to (1) provide a five-phase rehabilitation protocol following arthroscopic treatment for FAI and (2) report clinical and functional outcomes of patients following this protocol at minimum 1-year follow-up, in order to provide the surgeon and therapist with a protocol that is supported by clinical data. METHODS: All consecutive patients undergoing hip arthroscopy and subsequent five-phase rehabilitation protocol at a single institution from 1 April 2011 to 1 April 2012 were analysed. Inclusion criteria were as follows: no prior ipsilateral hip surgery, completion of the five-phase rehabilitation protocol, minimum 1-year follow-up, and documented outcome scores. Prospective outcomes were assessed with modified Harris hip score (MHHS) and hip outcome score (HOS). RESULTS: Fifty-two patients (19 male and 33 female) met the inclusion criteria with a median age of 42 (range 16-59) years. Mean MHHS, HOS-ADL, and HOS-sport scores at a mean 12.5 (range 12-15) months were 80.1 ± 19.9 (0-100), 83.6 ± 19.2 (13.2-100), and 70.3 ± 27.0 (0-100), respectively. CONCLUSION: This five-phase rehabilitation programme provides a framework where progression from surgery to increasing post-operative activity level can take place in a predictable manner. Patients following this rehabilitation protocol after hip arthroscopy demonstrated satisfactory clinical and functional outcomes, validating its implementation.