Cross-Sectional Analysis of the Distal Fibular Intramedullary Canal: A Cadaveric Evaluation.

Fractures of the distal fibula secondary to rotational ankle injuries are one of the most common injuries requiring surgical intervention. The aim of this study was to describe the anatomy of the distal fibular medullary canal as a means of aiding in surgical management with an intramedullary device. Twenty fresh cadaveric below-knee specimens (group 1, 10 in 2015, group 2, 10 in 2016) were dissected to expose the distal fibular. Fifteen (10 mm each) segments were sectioned with a sagittal saw from the distal tip proximally and measured with a digital caliper. In group I, the widest and narrowest fibular diameter was at the 20-mm interval (mean 15.02 mm) and 90-mm interval (mean 3.51 mm), respectively. From 70 to 120 mm, the mean diameter was less than 4.0 mm. In group 2, the widest and narrowest diameter was at the 20-mm interval (mean 15.05 mm) and 100-mm interval (mean 4.33 mm), respectively. From 70 to 140 mm, the mean diameter was less than 5.0 mm. The combined mean diameter at the 60- to 80-mm intervals were 4.99 ± 1.70, 4.35 ± 1.63, and 4.02 ± 1.35 mm, respectively. Based on our investigation, we propose an intramedullary device diameter of 4.5 to 5.0 mm in diameter with a length of 60 to 80 mm may provide most appropriate bony purchase to achieve acceptable cortical contact for expected osseous compression. LEVELS OF EVIDENCE: Level IV: Cadaveric case series.

First Metatarsal Head Osteochondral Defect Treatment With Particulated Juvenile Cartilage Allograft Transplantation: A Case Series.

BACKGROUND: Focal damage to articular cartilage, also called an osteochondral defect (OCD), can be a cause of pain and decreased range of motion. Recent advancements have led to transplantation techniques using particulated juvenile articular cartilage allograft. This technique has been applied to the first metatarsal head to a very limited degree, with no published results to our knowledge. The aim of this study was to review the clinical results of patients who underwent particulated juvenile cartilage allograft implantation for first metatarsal head OCDs. METHODS: We performed a retrospective consecutive case series study. Nine patients, at an average age of 41 years, were treated for symptomatic focal osteochondral defects of the first metatarsal head with particulate cartilage grafting from 2010 to 2016. Patients were contacted by phone to assess interest in returning to the office for follow-up, where weightbearing radiographs of the foot were obtained and a foot examination was performed. RESULTS: At an average follow-up of 3.3 years, 7 of 9 patients reported no pain with recreational activities and no patient required further operations. This patient cohort was physically active, with 6 of 9 listing running as a regular activity. The average overall American Orthopaedic Foot & Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scale questionnaire score was 85 (maximum 100), AOFAS pain 35.6 (maximum 40), and AOFAS function 40.1 (maximum 45). Patient satisfaction surveys correlated with the AOFAS scores and revealed that 7 of 9 patients were very satisfied with their results, 1 was satisfied, and 1 patient was very dissatisfied. CONCLUSION: Particulated juvenile cartilage allograft transplantation is a promising treatment option for symptomatic first metatarsophalangeal focal articular cartilage lesions. Further study is needed to demonstrate which lesions respond better to this type of cartilage graft versus traditional marrow-stimulating procedures. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Radiographic Assessment of a Medullary Total Ankle Prosthesis: A Test of Agreement and Reliability.

Total ankle replacement (TAR) is a viable alternative to ankle fusion in certain patients with end-stage ankle arthritis. Despite the importance of understanding alignment and movement of the prosthesis, there is no standardized radiographic method for evaluating the position and movement of the INBONE 2 prosthesis. The aims of this study were to describe a radiographic measurement protocol for INBONE 2 for clinical practice and research while determining the interobserver and intraobserver reliability using standard weightbearing radiographs. Fifteen patients were randomly selected with operative dates from January 2011 to January 2014 who underwent primary TAR using the INBONE 2 prosthesis. Most recent preoperative and first postoperative weightbearing anteroposterior and lateral radiographs were pulled and deidentified. Three foot and ankle surgeons blinded from the patient selection and deidentification, measured the described measurements on separate occasions. Intraobserver reliability: surgeon 1 had acceptable reliability for 9 of 13 continuous radiographic measurements (69.2%), surgeon 2 had acceptable reliability for 8 of 13 measurements (61.5%), and surgeon 3 had acceptable reliability for 12 of 13 measurements (92.3%). Interobserver reliability: among the first measurements, 6 of 13 continuous radiographic measurements (46.2%) had acceptable reliability. Among the second measurements, 7 of 13 measurements (53.8%) had acceptable reliability. Among the first and second measurements combined, 7 of 13 measurements (53.8%) had acceptable reliability. This study promotes the need for meticulous evaluation of annual radiographic findings following TAR in an effort to avoid catastrophic failure and represents moderate agreement can be obtained by employing the proposed measurements for surveillance of INBONE 2 TAR at annual postoperative visits. Measurements on the anteroposterior radiograph appear to demonstrate more consistent results for surveillance than lateral measurements. The intraobserver reliability results were somewhat superior to the interobserver reliability, implying more relevance for a single surgeon applying these measurements annually for postoperative surveillance. LEVELS OF EVIDENCE: Diagnostic, Level III.

Assessment of Bone Marrow Aspiration Site Pain in Foot and Ankle Surgery.

UNLABELLED: Bone marrow aspiration (BMA) is a validated technique to harvest progenitor cells. BMA has many uses in foot and ankle surgery; however, donor site morbidity is a concern. The purpose of this study was to compare the Visual Analog Scale (VAS) pain scores after BMA at 3 different sites (iliac crest, distal tibia, and calcaneus) over a 12-week postoperative recovery period. This was an institutional review board-approved prospective study of 40 patients who underwent BMA as an adjunct to their primary foot and ankle procedure. Each patient had BMA harvested from the ipsilateral anterior iliac crest, distal tibia, and lateral calcaneus at the time of surgery. Patient follow-up questionnaire forms were filled out at 2, 4, 8, and 12 weeks, with the primary outcome measure being VAS pain scores. Mean VAS scores averaged over the 12-week follow-up period were significantly higher in the calcaneus (20.8 ± 28.6) compared with the distal tibia (7.7 ± 17.6) and the iliac crest (4.2 ± 12.4; P < .05). No significant difference was found between the distal tibia and the iliac crest sites. At 12 weeks, all sites were about equal and without appreciable pain. Our data suggested that donor site selection for BMA affects postoperative pain levels, with BMA from the calcaneus resulting in significantly higher pain scores when compared with the iliac crest or distal tibia. The VAS pain score for the calcaneus was likely confounded by the high number of hindfoot/ankle surgeries performed in the ipsilateral foot. LEVELS OF EVIDENCE: Therapeutic, Level II: Prospective, comparative trial.

Effect of Dorsal Plate Positioning on Dorsiflexion Angle in Arthrodesis of the First Metatarsophalangeal Joint: A Cadaveric Study.

BACKGROUND: The relationship between dorsal plate positioning and final dorsiflexion angle after first metatarsophalangeal (MTP) joint fusion has not been well established. The main purpose of this study was to investigate whether changes in dorsal plate positioning along the longitudinal axis affect fusion dorsiflexion angle, as excessive dorsiflexion angles can lead to poor clinical results. METHODS: Ten cadaver foot specimens were randomly assigned to 2 groups for first MTP joint fusion: 1 group used a straight plate, and the other group used a 10-degree precontoured plate. After routine preparation, the plates were placed in an "ideal" position based on clinical and radiological examination. The plates were then moved proximally 3 mm and 6 mm from the initial site, with repeat imaging completed at each position. The radiological dorsiflexion angle was determined for each position, and the results were assessed. RESULTS: Placement of both straight and precontoured plates at positions more proximal from the initial position led to significant increases in dorsiflexion angles (P = .04), although the percentage change was larger in the precontoured plate group (P = .01). While placement of the plate 3 mm proximal from the perceived "ideal" position did increase the dorsiflexion angle, the percentage of specimens with dorsiflexion angles in the suggested optimal range changed minimally. Positioning at 6 mm from the starting point, however, led to significantly increased dorsiflexion angles for both plates (P = .004). CONCLUSION: Positioning the dorsal plate at more proximal locations leads to increasing dorsiflexion angles. Precontoured plates are more likely to lead to excessive dorsiflexion compared with straight plates regardless of plate position. CLINICAL RELEVANCE: Fusion at excessive dorsiflexion angles can be minimized with appropriate selection and proper positioning of the dorsal fusion plate along the longitudinal axis.

Laser targeting with C-arm fluoroscopy: effect on image acquisition and radiation exposure.

OBJECTIVES: Reducing unnecessary radiation exposure from medical imaging is paramount. This study assessed whether a laser aiming guide for C-arm fluoroscopy reduced the number of exposures needed to obtain an acceptable image, thereby reducing total fluoroscopy time for hip, knee, and ankle fluoroscopy. METHODS: An obese cadaver was placed supine on a radiolucent surgical table. Images were obtained by licensed radiologic technologists using a calibrated OEC 9900 Elite C-arm with laser targeting (LT) and without LT (NLT). Dosimeters were placed 1, 3, and 6 ft (30.5, 91.5, and 183 cm) away from the center of the C-arm at 90-degree angles at 2 levels, simulating thyroid and gonadal exposure. Posterior-anterior (PA) images of the bilateral lower extremities were obtained with each technician acquiring 24 centered images (hip, knee, and ankle) using both LT and NLT C-arm fluoroscopy. RESULTS: Total fluoroscopy time was reduced by 19% when using LT with a 39% reduction for the knee and a 29% reduction for the ankle. The addition of LT improved the likelihood of obtaining a centered image for knees and ankles but not for hips. The gonadal dosimetry data were significantly higher than the thyroid dosimetry badges at 1 ft. At the 3-ft zone, only trace amounts of radiation were detected; the 6-ft zone reported no radiation exposure in either group. CONCLUSIONS: LT helped with imaging knees and ankles with statistically significant reductions in fluoroscopy time and a statistically significant improvement of image quality defined as obtaining a centered PA image faster. The dosimetry badges detected minimal exposure at 3 ft and no detectable exposure at 6 ft at both levels.