Chronic Achilles Tendon Avulsion Repair: Central Third Fascia Slide Technique with Flexor Hallucis Longus Transfer.

Background: Chronic Achilles tendon defects are commonly associated with substantial impairment in gait and push-off strength, leading to decreased function1. These injuries cause a unique surgical dilemma, with no consensus surgical reconstruction technique for >6-cm gaps3. There are a multitude of surgical reconstruction techniques that rely on gap size as a determinant for preoperative planning1,2. The present article describes a technique for chronic Achilles tendon defects of >6 cm. The central third fascia slide (CTFS) technique with flexor hallucis longus (FHL) transfer provides adequate excursion and strength while avoiding use of allograft.2.The CTFS technique is a reconstructive technique that is utilized to treat large chronically gapped Achilles tendon tears, usually larger than 5 to 6 cm; however, recent literature has shown that intermediate gaps can be fixed with use of a combination of tendon transfers. The technique described here is a variation of the V-Y tendinoplasty and fascia turndown method in which the gastrocnemius complex fascia is slid down rather than being "turned down." This reconstructive technique, like its predecessor, restores function in damaged Achilles tendons3. Chronic gapping from a chronic Achilles tendon rupture can lead to decreased function and weakness. Patients may also experience fatigue and gait imbalance, leading to the need for surgical reconstruction to help restore functionality. Description: The CTFS technique utilizes a posterior midline incision, maintaining full-thickness flaps. A complete debridement of the degenerative Achilles tendon is performed, and the gap is measured. If the gap is >6 cm, the central third of the remaining Achilles and gastrocnemius fascia are sharply harvested. The FHL is transferred to the proximal Achilles footprint and held with use of an interference screw. The ankle is held in 15° to 25° of plantar flexion while the FHL shuttling suture is pulled plantarly and secured with a bio-interference screw. The fascial graft is then anchored to the calcaneus with use of a double-row knotless technique, maximizing osseous contact potential healing. Soft-tissue clamps are placed on the graft and on the gastrocnemius complex harvest site. The ankle is tensioned in nearly 30° of plantar flexion to account for known postoperative elongation. FiberWire (Arthrex) is utilized to secure the tension, then the remaining suture tape from the proximal insertional row is run up each side of the fascial graft in a running locking stitch, continuing proximally to close the harvest site. The use of an anchor-stay stitch helps to prevent elongation and maximizes construct strength. Alternatives: For patients who are poor surgical candidates or those with acceptable function, alternatives include nonoperative treatment and/or the use of a molded ankle foot orthosis. Most chronic Achilles tendon ruptures require surgery. Generally, a gap of <2 cm can be treated through primary repair with use of longitudinal and distally applied traction. For an Achilles gap of >2 cm but <6 cm, a V-Y gastrocnemius-lengthening procedure can utilized. Other methods such as autologous and local tendon transfers, advancement procedures, or a combination of these have been described as ways to treat gaps within this range. For gaps of >6 cm, there is insufficient literature to establish a single gold-standard reconstructive technique. Some surgeons have opted to utilize the turndown flap procedure, the FHL tendon transfer technique, or a combination of both. Rationale: The Achilles turndown flap technique can lead to the formation of scar tissue at the focal point of the turndown, a region also known as the hinge joint, and thus can perpetuate scarring of the repair site. To avoid this scarring, the central third fascia slide technique with FHL transfer is presented as a suitable reconstructive technique for chronic tendon defects of >6 cm. Expected Outcomes: Postoperatively, patients are managed according to a standard protocol. The first 2 weeks are non-weight-bearing with the foot in equinus in an L & U splint. At 2 to 4 weeks postoperatively, a walking boot with a 1.5-cm heel lift is applied, and crutches are utilized as the primary weight-bearing aid. At 4 to 6 weeks, the patient is transitioned to a 1-cm heel lift and may discontinue the use of crutches if they are able to walk without a limp. At 8 weeks, the patient may discontinue the use of the walking boot. At week 6 to 12, no heel lift is required. By approximately 12 weeks postoperatively, the patient should have regained full range of motion and should be able to walk without a limp. The patient should be able to resume activities of daily living by 3 to 4 months, with a gradual return to all physical activities by 4 to 6 months This postoperative protocol has produced favorable results. Ahmad et al. have reported the use of a similar protocol, with patients showing increased Foot and Ankle Ability Measure scores and decreased visual analog scale pain scores compared with the preoperative measurement2. Important Tips: Debride the Achilles until viable tendon is reached, then measure the defect.Tension the FHL and the fascia slide with the foot in 15° to 25° of plantar flexion.Perform a meticulous layered closure, preserving the paratenon as much as possible.Incomplete debridement may result in incompetent tissue.Incomplete closure of the fascia harvest site may predispose to seroma or hematoma formation.Not splinting for 10 to 14 days potentially predisposes the patient to wound breakdown. Acronyms and Abbreviations: CTFS = central third fascia slideFHL = flexor hallucis longusATTF = Achilles tendon turndown flapHPI = history of present illnessNWB = non-weight-bearingCAM = controlled ankle motionDVT = deep vein thrombosisMRI = Magnetic resonance imagingPMHx = past medical historyHTN = hypertensionSHx = social historyPE = physical examinationDF = dorsiflexionNVI = neurovascularly intactROM = range of motion.

Dorsal Cheilectomy Using Great Toe Metatarsophalangeal Joint Arthroscopy for the Treatment of Hallux Rigidus.

Great toe metatarsophalangeal joint (MTPJ) arthroscopy has been described in the literature for more than 50 years for treatment of a multitude of first MTPJ pathologies, including hallux rigidus, hallux valgus, and osteochondritis dissecans, among others. Despite this, the use of great toe MTPJ arthroscopy has not become widely used for treatment of these conditions as the result of reported difficulties with adequate visualization of the joint surface and manipulation of surrounding soft-tissue structures with the instruments available. We propose a simple technique with illustrations of the operating room setup and procedural steps to perform a dorsal cheilectomy in those with early-stage hallux rigidus using great toe MTPJ arthroscopy and a minimally invasive surgical burr in a way that is reproducible by foot and ankle surgeons.

Proximal Tibiofibular Joint Instability: An Underrecognized Cause of Lateral Knee Pain and Mechanical Symptoms.

Instability of the proximal tibiofibular joint is an uncommon and often unrecognized cause of lateral knee pain, mechanical symptoms, and instability. The condition results from one of three etiologies: acute traumatic dislocation, chronic or recurrent dislocations, and atraumatic subluxations. Generalized ligamentous laxity is a key predisposing factor for atraumatic subluxation. Instability of this joint may be in the anterolateral, posteromedial, or superior directions. Anterolateral instability is the most common type (80% to 85%) frequently occurring with hyperflexion of the knee with the ankle plantarflexed and inverted. Patients with chronic instability report lateral knee pain with snapping or catching often leading to a misdiagnosis of lateral meniscal pathology. Subluxations may be treated conservatively with activity modification, supportive straps, and knee-strengthening physical therapy. Chronic pain or instability is an indication for surgical treatment including arthrodesis, fibular head resection, or soft-tissue ligamentous reconstruction. Newly developed implants and soft-tissue graft reconstruction techniques provide secure fixation and stability with less invasive procedures and without the need for arthrodesis.

Talar Arthroscopic Reduction and Internal Fixation (TARIF): A Novel All-Inside Soft-Tissue-Preserving Technique.

Background: Talar arthroscopic reduction and internal fixation (TARIF) is an alternative approach for the operative fixation of talar fractures that may be utilized instead of more traditional open approaches such as medial, lateral, or even dual anterolateral. The TARIF approach allows for nearly anatomic fracture reduction and fixation of talar neck, body, and posterior dome fractures while minimizing the soft-tissue stripping and vascular injury associated with the standard anterolateral approach. Description: Following initial closed fracture reduction and any associated procedures, we recommend obtaining computed tomography scans of the injured ankle in order to evaluate the fracture pattern and allow for preoperative planning. Most patients can be positioned prone for this procedure, except for those with fractures associated with anterior loose bodies and those with neck fractures requiring reduction, which are both amenable to lateral positioning1. The feet are positioned off the end of the bed in a neutral position with room to plantar flex and dorsiflex the ankle freely for reduction maneuvers. Following induction of anesthesia and positioning of the patient, the fluoroscopic screen and arthroscopy equipment are positioned on the side opposite the surgeon. A mini C-arm is utilized for the fluoroscopy. The team may then proceed with preparing and draping the surgical field. The surgeon proceeds with creating posteromedial and posterolateral portals to view the fracture site. For talar neck fractures, we utilize standard posterolateral and posteromedial portals directly adjacent to the Achilles tendon at the level of the tip of the medial malleolus, which have previously been established as safe with respect to neurovascular structures4. Of note, for talar body fractures these portals are placed slightly more distal at the level of the distal fibula, allowing the screws to be placed perpendicular to the fracture site. An accessory sinus tarsi portal can be established if further reduction to correct varus is needed. The flexor hallucis longus tendon serves as a landmark throughout the case to maintain orientation. We prefer to utilize a 1.9-mm malleable arthroscopic NanoScope (Arthrex), which maximizes our view in the small subtalar space and allows for visualization over the talar dome. A shaver is then utilized to clear out the deep joint capsule and remove fracture hematoma. In our experience, after the initial primary reduction attempt by the orthopaedic trauma provider, the fracture is relatively stable and often held by an external fixator. The remaining reduction is performed with use of manipulation of the ankle in combination with an accessory sinus tarsi portal, utilizing an elevator or a small reduction tool in 1 of the posterior portals. We have also utilized percutaneous Kirschner wires to "joystick" the fragments prior to the placement of the guidewires. We then place multiple 1.1-mm guidewires under direct arthroscopic and fluoroscopic visualization, utilizing the flexor hallucis longus tendon as our safe margin to ensure that we are lateral on the posterior talar dome. This approach in turn allows us to ensure the integrity of the neurovascular structures, such as the tibial artery and nerve medially as well as the sural nerve laterally. Finally, cannulated headless compression screws are passed over the guidewire to achieve fixation. The senior author (K.D.M.) prefers fully threaded, cannulated 3.5-mm titanium headless compression screws because the cannulation allows the guidewires to be placed through the posterolateral and posteromedial portals, while the headless design allows the screws to be placed under the articular cartilage. Additionally, the use of titanium allows for improved postoperative magnetic resonance imaging quality as well as favorable biomechanics as titanium has a modulus of elasticity similar to bone. After drilling is complete, we sequentially tighten the screws by hand to prevent varus or valgus angulation. Although we have not experienced failure or a poor bite when utilizing the 3.5-mm fully threaded compression screw, we have found that the partially threaded screw can at times have a poorer bite. Additionally, we select a 3.5-mm screw rather than a larger screw-say 5.5 mm-as we have found that the larger screws do not easily pass through our portals, which are minimal in size when utilizing this approach. Throughout this process, fluoroscopy, in tandem with arthroscopy, is obtained in multiple views to ensure that fixation and orientation are appropriate and the screws are in the optimal position, off of the articular surface. If large osseous defects or collapse are encountered, an accessory anteromedial portal is utilized to add grafting material. Following confirmation of adequate fracture fixation, final arthroscopic images of the talar dome continuity, subtalar continuity, and ankle joint during range of motion are obtained. The portal sites are closed with use of 3-0 nonabsorbable sutures, and a well-padded L and U splint is applied postoperatively. Alternatives: Alternatives include the standard anterolateral approach to fixation or dual anterior approach, a medial or lateral approach, and external fixation with interval operative fixation. Rationale: TARIF is indicated for reduction of a wide variety of talar fractures, including neck, body, and posterior facet fractures, and offers the added advantage of minimizing the soft-tissue stripping and vascular injury associated with the standard anterolateral approach. Additionally, TARIF is well suited for patients with a compromised soft-tissue envelope or associated vascular injury, such as those with open-fracture pathology, because the approach avoids further disruption of these tissues. The overall aim of the procedure is to obtain adequate fracture reduction while avoiding the neurovasculature and soft-tissue envelope that would commonly be encountered anteriorly. The procedure is completed through 2 incisions, a posteromedial portal and a posterolateral portal, through which the fracture is visualized, reduced, and fixated using cannulated screws. The fixated talus is tested through its range of motion while under arthroscopy and fluoroscopy to ensure adequate fixation while preserving range of motion. Expected Outcomes: The TARIF procedure has been shown to successfully treat many complex talar fractures2. We theorize that this procedure produces equivalent outcomes when compared with the standard approaches to fracture fixation, with the added benefit of avoiding excessive soft-tissue disruption and neurovascular compromise. Our arthroscopic approach allows for direct visualization of articular injuries and reduction, with the ability to evacuate loose bodies and fracture hematoma, reducing matrix metalloproteinases (MMPs) known to cause posttraumatic ankle arthritis1,3. Multiple case series have assessed the use of this technique, showing preserved range of motion and minimal residual pain or disability, as measured with use of multiple scoring systems such as the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot scale1,2. Important Tips: Immediately after accessing the ankle via the operative portals, identify the flexor hallucis longus tendon to prevent iatrogenic injury to the neurovascular bundle.Plantar flexion of the ankle while applying anterior force to the talar body often aids in reduction.Place the medial guidewire directly adjacent to the flexor hallucis tendon in order to ensure that it is medial enough.Utilize anterior-to-posterior fluoroscopic images of the foot and ankle to ensure screw placement.Directly visualize the fracture site as the screws are sequentially tightened in order to prevent malalignment.Countersink all screw heads and directly verify with arthroscopic visualization. Acronyms & Abbreviations: MVC = motor vehicle collisionXR = x-ray (radiograph)CT = computed tomographyEx-fix = external fixatorMRI = magnetic resonance imagingFT = fully threadedFHL = flexor hallucis longusAP = anteroposteriorROM = range of motionDVT = deep vein thrombosisBID = bis in die (twice daily dosing).

Low-Flow Ankle Arthroscopy for Gunshot Wounds With Retained Intra-Articular Ballistic.

Gunshot injuries to the foot and ankle can cause unique and challenging situations for orthopaedic surgeons. The foot and ankle have limited soft-tissue coverage and highly congruent joint spaces, leading to injuries that are often intra-articular with substantial tissue loss. These injuries are often confounded by feet shod in footwear that is pulled into the path of the missile and corresponding tissue. Thus, we report our experience of using low-flow arthroscopy for extraction of retained ballistics, while irrigating and debriding the path of the missile.

Review of Common Clinical Conditions of the Proximal Tibiofibular Joint.

Current literature is limited with respect to the proximal tibiofibular joint (PTFJ) and clinical conditions relating to the PTFJ. Diagnosis and treatment of conditions that affect the PTFJ are not well described and are a topic of debate among many physicians. This manuscript aims to review and summarize the most recent literature that relates to traumatic dislocations, fractures, chronic instability, and osteoarthritis, with a focus on both diagnostic and treatment strategies of these conditions. We also review PTFJ anatomy, biomechanics, and the clinical presentation of some common PTFJ conditions.

Suspensory Versus Aperture Fixation of a Quadrupled Hamstring Tendon Autograft in Anterior Cruciate Ligament Reconstruction: A Meta-analysis.

BACKGROUND: Hamstring grafts have become a popular choice for anterior cruciate ligament (ACL) reconstruction; however, the most effective means of fixation of these soft tissue grafts is unknown. PURPOSE: To determine whether suspensory or aperture fixation of hamstring tendon autografts provides better stability and clinical outcomes in ACL reconstruction. STUDY DESIGN: Meta-analysis. METHODS: A literature search of studies reporting single-bundle ACL reconstructions using 4-stranded hamstring tendon autografts with aperture or suspensory fixation with a minimum 24-month follow-up was conducted. Stability and clinical outcomes were compared for aperture versus suspensory fixation. Knee stability was measured with the Lachman or pivot-shift test or KT-1000 arthrometer side-to-side difference (SSD), and outcomes were determined with the International Knee Documentation Committee (IKDC), Tegner, and Lysholm scores as well as graft failures. A random-effects model with a pooled estimate for the between-study variance was used to estimate proportions or means for each outcome and its corresponding 95% CI. RESULTS: Forty-one studies were included, of which 20 utilized suspensory fixation techniques and 21 utilized aperture fixation techniques. A >3-mm SSD was seen more often in the aperture group than the suspensory group, which was statistically significant ( P < .0001), but there was no significant difference between groups for a >5-mm SSD ( P = .53). The aperture group demonstrated significantly more graft ruptures than did the suspensory group ( P = .03). There were no statistically significant differences in Lachman grade 0 ( P = .76), grade 1 ( P = .89), and grade 2 ( P = .55) or pivot-shift grade 0 ( P = .72), grade 1 ( P = .97), and grade 2 ( P = .28). There was no statistically significant difference in mean continuous IKDC ( P = .80), Tegner ( P = .34), or Lysholm ( P = .84) scores. CONCLUSION: This meta-analysis demonstrated improved overall arthrometric stability and fewer graft ruptures using suspensory fixation compared with aperture fixation of a quadrupled hamstring tendon autograft in ACL reconstruction. There were no differences in IKDC, Lysholm, Lachman, and pivot-shift outcomes between suspensory and aperture fixation.