Effect on Clinical Outcome and Growth Factor Synthesis With Adjunctive Use of Pulsed Electromagnetic Fields for Fifth Metatarsal Nonunion Fracture: A Double-Blind Randomized Study.

BACKGROUND: Electromagnetic bone growth stimulators have been found to biologically enhance the bone healing environment, with upregulation of numerous growth factors. The purpose of the study was to quantify the effect, in vivo, of pulsed electromagnetic fields (PEMFs) on growth factor expression and healing time in fifth metatarsal nonunions. METHODS: This was a prospective, randomized, double-blind trial of patients, cared for by 2 fellowship-trained orthopedic foot and ankle surgeons. Inclusion criteria consisted of patients between 18 and 75 years old who had been diagnosed with a fifth metatarsal delayed or nonunion, with no progressive signs of healing for a minimum of 3 months. Eight patients met inclusion criteria and were randomized to receive either an active stimulation or placebo PEMF device. Each patient then underwent an open biopsy of the fracture site and was fitted with the appropriate PEMF device. The biopsy was analyzed for messenger-ribonucleic acid (mRNA) levels using quantitative competitive reverse transcription polymerase chain reaction (QT-RT-PCR). Three weeks later, the patient underwent repeat biopsy and open reduction and internal fixation of the nonunion site. The patients were followed at 2- to 4-week intervals with serial radiographs and were graded by the number of cortices of healing. RESULTS: All fractures healed, with an average time to complete radiographic union of 14.7 weeks and 8.9 weeks for the inactive and active PEMF groups, respectively. A significant increase in placental growth factor (PIGF) level was found after active PEMF treatment (P = .043). Other factors trended higher following active PEMF including brain-derived neurotrophic factor (BDNF), bone morphogenetic protein (BMP) -7, and BMP-5. CONCLUSION: The adjunctive use of PEMF for fifth metatarsal fracture nonunions produced a significant increase in local placental growth factor. PEMF also produced trends toward higher levels of multiple other factors and faster average time to radiographic union compared to unstimulated controls. LEVEL OF EVIDENCE: Level I, prospective randomized trial.

Failed Surgical Management of Acute Proximal Fifth Metatarsal (Jones) Fractures: A Retrospective Case Series and Literature Review.

UNLABELLED: Nonunion, delayed union, and refracture after operative treatment of acute proximal fifth metatarsal fractures in athletes is uncommon. This study was a failure analysis of operatively managed acute proximal fifth metatarsal fractures in healthy athletes. We identified 149 patients who underwent operative treatment for fifth metatarsal fractures. Inclusion criteria isolated skeletally mature, athletic patients under the age of 40 with a minimum of 1-year follow-up. Patients were excluded with tuberosity fractures, fractures distal to the proximal metaphyseal-diaphyseal region of the fifth metatarsal, multiple fractures or operative procedures, fractures initially treated conservatively, and medical comorbidities/risk factors for nonunion. Fifty-five patients met the inclusion/exclusion criteria. Four (7.3%) patients required a secondary operative procedure due to refracture. The average time to refracture was 8 months. All refractures were associated with bent screws and occurred in male patients who participated in professional basketball, professional volleyball, and college football. The average time for release to progressive weight-bearing was 6 weeks. Three patients were revised to a bigger size screw and went on to union. One patient was revised to the same-sized screw and required a second revision surgery for nonunion. All failures were refractures in competitive athletes who were initially treated with small diameter solid or cannulated stainless steel screws. The failures were not associated with early postoperative weight-bearing protocol. Maximizing initial fixation stiffness may decrease the late failure rate in competitive athletes. More clinical studies are needed to better understand risk factors for failure after screw fixation in the competitive, athletic population. LEVEL OF EVIDENCE: Prognostic, Level IV: Case series.

Safety analysis of cryopreserved amniotic membrane/umbilical cord tissue in foot and ankle surgery: a consecutive case series of 124 patients.

Cryopreserved amnion tissues derived from amniotic membrane/umbilical cord (AM/UC) have been used extensively in ophthalmology for minimizing postoperative inflammation, pain, and adhesion formation following various surgical procedures. There is limited data in the current literature regarding the use of amnion tissue product in foot and ankle surgery. The purpose of this retrospective study is to report the short-term safety profile after in vivo application of cryopreserved AM/UC tissue use in foot and ankle surgery. A retrospective consecutive case series was performed for cases where amnion tissue was used with a minimum follow-up of 120 days between 2011 and 2012. The clinical outcomes of interest were postoperative infections, delayed or nonhealing wounds, adverse surgical site reactions, and repeat surgery for formal irrigation and debridement. One hundred twenty-four patients qualified for inclusion. Cryopreserved AM/UC tissue was introduced into the surgical wound and placed adjacent to the compromised and repaired tendons, most frequently in peroneal and Achilles tendon repairs. In this level IV consecutive case series cohort, there was an overall wound complication rate of 5.64%, with a re-operation rate of 1.6% (2/124). In each of these cases, patients had an irrigation and debridement with ultimate successful wound healing. The results of this study demonstrate that the use of amnion tissue in the foot and ankle setting is safe with a decreasing trend in overall complication rates compared with historically published norms.

Talonavicular joint fixation: a biomechanical comparison of locking compression plates and lag screws.

BACKGROUND: Fusion of the talonavicular (TN) joint is an effective treatment for hindfoot pain and deformity. Nonunion in hindfoot fusion procedures is most common in the TN joint. The purpose of this study was to evaluate and compare the mechanical stability of 2 different forms of fixation for isolated fusion of the TN joint. MATERIALS AND METHODS: 13 fresh-frozen cadaver foot and ankles were procured and mounted vertically in a robotic biomechanical testing platform and tested before and after operative fixation; 7 specimens received 2 retrograde lag screws (2S), and 6 specimens received a locked compression plate with 1 retrograde lag screw (PS). A constant Achilles tendon load was initially applied followed by internal or external rotation (ER) of the foot and axial compression through the tibia. The relative motion of the talus and navicular bones was tracked using 3-dimensional optoelectric targets. Motion data were recorded in the traditional anatomical reference frame and then transformed into the TN joint frame. RESULTS: In the TN joint frame, relative to the intact (preoperative) state, the plate fixation group PS showed a significant reduction in separation along the long axis of the talus in 3 out of the 4 loading scenarios (P values = .007, .02, and .05). The PS construct also significantly restricted the flexion-extension motion at the joint compared with the 2S construct, during the ER tests (P values = .002 and .001). CONCLUSIONS: In our simulated weight-bearing model, a dorsal locked compression plate with 1 retrograde screw was more effective at limiting the 3D motion across the TN joint compared with the traditional construct of 2 retrograde screws.

Exposure of the medial talar dome: bi-plane chevron medial malleolus osteotomy.

Open surgical exposure of the medial aspect of the talus is primarily indicated for osteochondral lesions of the talus and talar body fractures. Secondary to the difficulty of access, a variety of techniques have been described. The surgical techniques described in the literature include transmalleolar access windows, medial and anterior tibial osteotomies, and resection osteotomies (plafondoplasty). The purpose of this article is to describe the surgical technique for the bi-planar chevron osteotomy of the medial malleolus. This osteotomy can provide full exposure to the entire medial aspect of the talus. The orientation of the osteotomy allows for perpendicular placement of instrumentation on the medial half of the talus and is particularly useful for cartilage transplant procedures. The technique is reproducible and has a low complication rate when performed correctly.

Immediate weight bearing of comminuted supracondylar femur fractures using locked plate fixation.

Comminuted supracondylar femur fractures (AO-OTA 33A3) are commonly treated with locked plates. Weight bearing is generally restricted for 6 to 12 weeks until radiologic evidence exists of sufficient callous to support weight bearing. Recent clinical studies have reported high nonunion rates with distal femur locked plates. In an attempt to induce beneficial motion across the fracture site, some studies have recommended earlier weight bearing. The purpose of the current study was to determine the biomechanical feasibility of an immediate weight-bearing rehabilitation protocol to encourage healing of distal femur fractures treated with lateral locked plate fixation.Sixteen fresh-frozen cadaveric femora were used for this study. A 2.5-cm supracondylar gap osteotomy was made. Ten-hole, 4.5-mm distal femur locking plates were used with a standardized screw configuration that maximized the working length. The specimens were placed in a servohydraulic testing machine and axially loaded (unidirectional) at 1 Hz for up to 200,000 cycles. Failure was defined as 1 cm of deformation of the construct. The staircase method was used to determine the fatigue limit of the construct. The fatigue limit was calculated to be 1329±106 N. No specimen failed through the non-locking diaphyseal screws. Plastic deformation, when present, occurred at the metaphyseal flare of the plate. The fatigue limit of the locked plate constructs equaled 1.9 times body weight for an average 70-kg patient over a simulated 10-week postoperative course. Given that distal femoral loads during gait have been estimated to be more than 2 times body weight, the data from this study do not support immediate full weight bearing.

Tenodesis reconstruction for chronic ankle instability: graft considerations and structures at risk with tunnel placement.

UNLABELLED: Lateral ankle ligament surgical reconstruction can take many forms, including anatomic and nonanatomic reconstructions. The nonanatomic reconstructions require the use of autograft or allograft tendons to recreate the vectors of the injured anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL). The purpose of this study was to determine the minimum, maximum, and average graft length requirements for a modified Chrisman-Snook procedure. The structures at risk during drilling of the bone tunnels were documented to guide recommendations for tunnel placement. Modified Chrisman-Snook lateral ligament reconstructions were performed on 10 cadaveric below-the-knee specimens, with no known pathology. Transosseus tunnels were placed through and through the fibula, talus, and calcaneus at the origin and insertion sites of the ATFL and CFL. The minimum, maximum, and average graft length requirements were 91 mm, 170 mm, and 120.7 ± 23.84 mm, respectively. The overall average graft requirement was approximately 120 mm. The length of graft was correlated with the height of the patient. Medial structures that were directly encountered, in at least one specimen, with the transosseus tunnels included the tibial nerve, tibial artery and flexor hallucis longus tendon. The posterior tibial nerve was the structure at greatest risk. The length of the graft, when performing the modified Chrisman-Snook, should measure approximately 120 mm, but considerable variability exists depending on the size of the patient. To avoid injury to medial structures, the transosseus tunnels should be made using either a blind hole technique or guide wire to avoid perforating the medial cortex. LEVELS OF EVIDENCE: Cadaveric, Level V.

Interpositional arthroplasty of the first metatarsophalangeal joint using a regenerative tissue matrix for the treatment of advanced hallux rigidus: 5-year case series follow-up.

BACKGROUND: Painful osteoarthritis of the first metatarsophalangeal (MTP) joint, known as hallux rigidus, can be difficult to treat in young and active patients that who fail conservative treatment. The purpose of this study is to report the 5-year follow-up of a joint preservation technique for the treatment of advanced hallux rigidus. METHODS: Preservation of the first MTP joint is performed using a human acellular dermal regenerative matrix as an interpositional arthroplasty graft. A retrospective chart review was performed and compared with follow-up modified American Orthopedic Foot and Ankle scores (AOFAS) obtained by telephone. Of the first 9 consecutive patients in the original study cohort, 6 patients were available for follow-up. The outcome measures include AOFAS modified for pain and function, reoperation rates, and overall satisfaction with the procedure. RESULTS: The average follow-up was 5.43 years. No patient had a subsequent fusion or additional procedure performed on their first MTP joint. Average preoperative modified AOFAS were 38 (range, 34 to 43). Average postoperative AOFAS were 65.8 (range, 58 to 68). All patients were satisfied with their results. CONCLUSION: Interpositional arthroplasty of the first MTP joint using a regenerative tissue matrix has led to reliable pain relief and preserved function at an average follow-up of 5.4 years in 6 patients. The authors recommend this technique to active patients with advanced hallux rigidus who want to delay a fusion of their first MTP joint.

Periostitis secondary to prolonged voriconazole therapy in a lung transplant recipient.

This article reports a case of perostitis deformans in a lung transplantation patient taking the fluoride-containing medication voriconazole, a relatively new and potent anti-fungal. The patient had a normal range of motion in all joints and a normal gait. On radiographs at presentation, multifocal areas of periostitis were visualized involving the left-hand first, second, and third proximal phalanx shafts. Similar periostitis was present on the left-hand third, fourth, and fifth middle phalanx shafts. Plain radiographs of the right hand also demonstrated multifocal periostitis of the third and fourth proximal and middle phalanges. Aggressive periostitis at the level of the right fourth proximal and middle phalanges was also present. Given her long-term treatment with voriconazole and a presentation consistent with periostitis deformans, voriconazole was presumed to be the offending agent and was replaced with itraconazole. The patient's symptoms resolved shortly after withdrawal of voriconazole.Voriconazole-associated periostitis has only recently been reported in the literature. Food and Drug Administration-approved in 2002, voriconazole is efficacious in treating serious, invasive fungal infections that are generally seen in immunocompromised patients. Due to the novel nature of voriconazole and the uncommon indications for its long-term use, the periostitis deformans described in this article may be unfamiliar to the orthopedic surgeon. Consequently, a patient presenting with bone pain and periosteal involvement on plain radiographs may provoke a broad, expensive, and ultimately unnecessary diagnostic evaluation. The clinical case and imaging findings presented here can help to promote understanding of this benign condition and its simple cure: voriconazole discontinuation.

Fixation of first tarsometatarsal arthrodesis: a retrospective comparative cohort of two techniques.

BACKGROUND: Presently, indications for the Lapidus procedure include patients with many pathologies of the first metatarsocuneiform joint. Currently the standard in many areas is that of two or three crossed screws through the first tarsometatarsal region. This type of fixation requires an extended period of nonweightbearing and may be difficult for patient compliance. MATERIALS AND METHODS: The present study is a retrospective comparison of crossed screw fixation to locking plate fixation without a lag screw on union rates, time to weightbearing, and complications. RESULTS: One hundred forty-three first TMT fusions met the inclusion criteria. There were 96 fused by crossed screw construct (CS) and 47 by the locked plate with or without compression screw (LP). There was a significant difference in time to full weightbearing and union rate. Time to full weightbearing was 8.8 (range, 3 to 16) weeks and 7.8 (range, 1.5 to 34) weeks in the CS and LP groups, respectively (p < 0.001). Union rate was 89.4% (88 of 96 joints) and 98.5% (46 of 47 joints) in the CS and LP groups, respectively (p < 0.001). CONCLUSIONS: We found that when using a dorsal-medial locked plate with or without lag screw lead to a superior rate of union compared to standard crossed screw constructs even while allowing earlier return to full weightbearing.

The midfoot sprain: a review of Lisfranc ligament injuries.

The subtle clinical and radiographic findings of an unstable Lisfranc ligament injury can be easily misdiagnosed as a stable midfoot sprain. Appropriate treatment ranges from conservative management to surgery, depending on the extent of ligament disruption and subsequent joint instability. Initial evaluation with non-weight bearing radiographs is often normal in unstable injuries. The results of missed or inappropriately treated Lisfranc injuries are poor. Chronic joint instability can lead to persistent pain, degenerative joint disease, and decreased functional capacity. Inability to return to previous levels of activity may result from painful midfoot arthritis. It is important to have a high index of suspicion for unstable Lisfranc injuries in patients who present with midfoot pain after low-energy injuries. Stress radiographs and magnetic resonance imaging can help differentiate between stable and unstable ligament sprains. Referral to an orthopedic surgeon is appropriate for injuries that result in joint diastasis. Long-term outcomes are optimized by early anatomic reduction.