Cheilectomy With or Without Cryopreserved Amniotic Membrane-Umbilical Cord Allograft for Hallux Rigidus.

BACKGROUND: For hallux rigidus, dorsal cheilectomy remains a treatment option even with advances in interposition techniques and devices. Cheilectomy aims to alleviate dorsal impingement and improve pain and function as well as range of motion. Cryopreserved umbilical cord allograft, with properties to mitigate inflammation and scar formation, has theoretical benefit for improving outcomes following cheilectomy. In this first prospective randomized and blinded cheilectomy study reported, we aimed to compare outcomes between cheilectomy alone and cheilectomy with umbilical cord allograft. METHODS: Patients were randomized to cheilectomy alone (CA) or cheilectomy with cryopreserved umbilical cord (ie, amniotic membrane-umbilical cord [AM-UC]). Patients were evaluated with American Orthopaedic Foot & Ankle Society (AOFAS), Foot Function Index (FFI), and visual analog scale (VAS) pain outcomes collected preoperatively and at 6 months and 1 year postoperatively. In addition, radiographic range of motion data were collected using stress radiographs. Fifty-one patients (26 AM-UC, 25 CA) completed the study, with 5 bilateral surgeries in the AM-UC group and 2 in the CA group, totaling 31 and 27 feet, respectively. RESULTS: The AM-UC group had statistically significant improved AOFAS and FFI scores at 1 year compared with the CA group, but there was no difference at 6 months. There was no significant difference between groups for VAS-pain scores at any time point, but overall VAS-pain improved in both groups from preoperative values. There was no significant difference in range of motion (total arc) between groups and changes in range of motion (total arc) in both groups from preoperative to 1 year postoperative were small. CONCLUSION: We present the results of the first randomized and blinded prospective study of cheilectomy surgery patients. When appropriately selected, cheilectomy remains a good option for patients with symptomatic hallux rigidus. Cryopreserved umbilical cord is a potential adjuvant to cheilectomy, with 1-year results showing improvements in functional outcome scores. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Does formal vs home-based physical therapy predict outcomes after ankle fracture or ankle fracture-dislocation?

Background: Ankle fractures are among the most common injuries treated by orthopaedic surgeons. Various postoperative rehabilitation strategies have been promoted, but the ability to improve patient-reported functional outcome has not been clearly demonstrated. We aim to evaluate outcomes associated with clinic-based, physical therapist-supervised rehabilitation (Formal-PT) compared to surgeon-directed rehabilitation (Home-PT). Methods: This prospective observational study included patients with operative bimalleolar or trimalleolar ankle fractures with or without dislocation (n = 80) at a Level I trauma center. Patients were prescribed PT per the surgeon's practice pattern. Patient-reported functional outcomes at 6 months and complication rates were compared between groups. Results: Of the 80 patients, 38 (47.5%) patients received Formal-PT; the remaining received Home-PT. Thirty-four patients (89.5%) attended ≥1 PT session. Number of sessions attended ranged from 1 to 36 (mean = 16). Receipt of Formal-PT did not differ by injury characteristics or demographics. Of patients with private insurance, 57% were prescribed Formal-PT vs 7% of uninsured patients (P = .033). FAAM and Combination SMFA scores at 6 months were similar between groups (Formal-PT: 69.7, 20.1; Home-PT: 70.9, 24.4; P = .868, .454, respectively). Postoperative complications were rare and equivalent between groups. Conclusions: Comparison of outcomes between patients with operatively treated displaced ankle fractures/dislocations with Formal-PT vs Home-PT showed no difference in SMFA and FAAM scores. These findings suggest patients receiving supervised PT produced a similar outcome to those under routine physician-directed rehabilitation at 6 months. The cost for therapy averaged $2012.96 per patient receiving Formal-PT.

Operative Technique: Interposition Arthroplasty and Biological Augmentation of Hallux Rigidus Surgery.

Hallux rigidus is the most common arthritic malady to afflict the foot. A host of nonoperative measures can alleviate pain, and with failure of conservative treatment, joint preserving and joint sacrificing procedures can be used to treat persistent symptoms. Although arthrodesis is an effective pain-relieving operation, loss of motion at the hallux metatarsophalangeal joint may limit the patient's function and can be an unacceptable solution. Various types of interposition arthroplasty can offer a motion-preserving alternative to arthrodesis.

The use of amniotic membrane/umbilical cord in first metatarsophalangeal joint cheilectomy: a comparative bilateral case study.

Hallux rigidus is marked by degenerative osteoarthritis of the first metatarsophalangeal (MTP) joint with pain and stiffness in the joint, with first ray plantarflexion and dorsiflexion, swelling and inflammation surrounding the first MTP joint, and reduced sagittal plane motion. Treatment of mild cases of hallux rigidus focuses on conservative, nonsurgical treatments such as rigid orthotic devices, physical therapy, pain relievers, and corticosteroid injections. Hallux rigidus recalcitrant to conservative management can be treated with dorsal cheilectomy to palliate pain at extremes of motion. Post-cheilectomy scarring and stiffness of the joint result in a diminished arc of motion over time. This clinical problem is not readily addressed by current treatment methods. Amniotic membrane/umbilical cord has the potential to modulate adult wound healing by suppressing stromal cellular-based inflammation and reducing scarring. Cryopreserved amniotic membrane/umbilical cord (AM/UC) tissue has been successfully used for minimizing postoperative inflammation, pain, and adhesion formation following various soft tissue reconstructive procedures, particularly in ophthalmology. Recently, the therapeutic potential of cryopreserved AM/UC has been expanded for use in lower extremity reconstructive procedures, specifically where wound healing and adhesion prevention are of clinical significance. This article reviews a bilateral case report experience of the novel utility of cryopreserved AM/UC tissue as an adhesion barrier and inflammatory modulator in conjunction with dorsal cheilectomy for treatment of hallux rigidus.