Locked Dorsal Compression Plate Arthrodesis for Degenerative Arthritis of the Midfoot.

Midfoot arthrodesis is the accepted surgical treatment for symptomatic midfoot arthritis. The published literature has focused on joint-spanning static fixation. Several companies have developed diamond-shaped locked dorsal compression plates, which allow for longitudinal joint compression. After dorsal plate insertion, a spreader device opens the arms of the plate mediolaterally, which allows the plate to compress longitudinally. This work describes outcomes of such locked dorsal compression plates for midfoot arthritis at a single institution. We reviewed 62 patients who underwent midfoot arthrodesis for symptomatic midfoot arthritis using locked dorsal compression plates over a 7-year period. A total of 173 joints were spanned for fusion. The primary outcome measure was radiographic union and visual analog scale pain scores. Characteristics of patients who experienced nonunion versus those who had union were evaluated. Of the 173 joints, there was a 81.5% fusion rate (141/173 joints) and 14 patients experienced nonunion. There was a statistically significant difference in the average number of joints spanned in patients with nonunion (3.6) and patients with union (2.5) (p = .02). Locked dorsal compression plate arthrodesis is a viable technique for achieving midfoot fusion. This mechanical method of compression does not, however, lend itself to improved fusion rates compared with prior reports. A greater number of arthrodesis sites is associated with a higher nonunion rate. Emerging technology using newer materials and improved biomechanical designs may show improved results.

What Preoperative Optimization Should Be Implemented to Reduce the Risk of Surgical Site Infection/Periprosthetic Joint Infection (SSI/PJI) in Patients Undergoing Total Ankle Arthroplasty (TAA)?

RECOMMENDATION: We recommend that patients awaiting total ankle arthroplasty (TAA) be optimized prior to surgery by implementing skin cleansing, nutritional status enhancement, glycemic control, body mass index (BMI) optimization, smoking cessation, and management of immune-modulating comorbidities. At the time of surgery, there is strong evidence that optimal preparation of the surgical site with an alcohol-containing agent, weight-based and timely administration of antibiotic prophylaxis, and reducing operating room traffic should also be put in place. LEVEL OF EVIDENCE: Moderate. DELEGATE VOTE: Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

What Is the Treatment "Algorithm" for Infection After Ankle or Hindfoot Arthrodesis?

RECOMMENDATION: There is no universal algorithm for addressing the infected ankle or subtalar arthrodesis. A potential algorithm created by consensus is. LEVEL OF EVIDENCE: Consensus. DELEGATE VOTE: Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Does Intra-articular Injection of the Ankle With Corticosteroids Increase the Risk of Subsequent Periprosthetic Joint Infection (PJI) Following Total Ankle Arthroplasty (TAA)? If So, How Long After a Prior Intra-articular Injection Can TAA Be Safely Performed?

RECOMMENDATION: Every intra-articular injection of the ankle is an invasive procedure associated with potential healthcare-associated infections, including periprosthetic joint infection (PJI) following total ankle arthroplasty (TAA). Based on the limited current literature, the ideal timing for elective TAA after corticosteroid injection for the symptomatic native ankle joint is unknown. The consensus workgroup recommends that at least 3 months pass after corticosteroid injection and prior to performing TAA. LEVEL OF EVIDENCE: Limited. DELEGATE VOTE: Agree: 92%, Disagree: 8%, Abstain: 0% (Super Majority, Strong Consensus).

Comparison of Single-Agent Versus 3-Additive Regional Anesthesia for Foot and Ankle Surgery.

BACKGROUND: This study compared the results of regional blocks containing a single anesthetic, bupivacaine, with those containing bupivacaine and 3 additives (buprenorphine, clonidine, and dexamethasone) in patients undergoing foot and ankle surgery. METHODS: Eighty patients undergoing foot and ankle surgery over a 9-month period were prospectively enrolled and randomized to receive a peripheral nerve block containing either a single anesthetic (SA) or one with 3 additives (TA). Patients, surgeons, and anesthesiologists were blinded to the groups. Patients maintained pain diaries and were evaluated at 1 and 12 weeks postoperatively. Fifty-six patients completed the study. RESULTS: The TA group had a longer duration of analgesic effect than the SA group (average 82 vs 34 hours, P < .05). Forty-eight hours after surgery, 93% of SA blocks, compared with 34% of TA blocks, had completely worn off. The TA group had a longer duration of sensory effects. At 3 months, 10 of 26 (38.5%) TA patients, compared with 3 of 30 (10%) SA patients, reported postoperative neurologic symptoms. Pain scores in both groups were not statistically different at 1 week or 3 months after surgery. Patients in both groups were similarly satisfied with their blocks. CONCLUSION: Both types of nerve blocks provided equivalent pain control and patient satisfaction in patients undergoing foot and ankle surgery. The 3-additive agent blocks were associated with a longer duration of pain relief and a longer duration of numbness, as well as higher rates of postoperative neurologic symptoms. Longer pain relief may be obtained at the cost of prolonged sensory deficits. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Ankle Arthrodesis Using an Anterior Titanium Dual Locked Plating Construct.

Ankle arthrodesis is currently the reference standard treatment for end-stage tibiotalar arthrosis. The fusion rates have varied in the published data from 59% to 100%. We reviewed 60 cases of consecutive anterior ankle arthrodesis using an anterior dual locked plating construct with respect to the fusion rate, time to fusion, pain relief, and complications. The patients were followed up for a mean of 1.1 years (range 16 weeks to 4 years). We found that our fusion rate was 97% for ankles not requiring structural allograft. The mean interval to fusion was 11.7 weeks, excluding those with a structural allograft. The mean visual analog scale pain scores decreased from 7 preoperatively to 2 at the final follow-up visit. Anterior ankle arthrodesis with dual locked plating provides excellent results with respect to the fusion rate with a low complication rate.

Plantar Plate Repair for Lesser Metatarsophalangeal Joint Instability.

BACKGROUND: Lesser metatarsophalangeal (MTP) joint instability is a common cause of forefoot pain. Advances in operative technique and instrumentation have made it possible to anatomically treat plantar plate tears through a dorsal approach. Our goal was to evaluate the subjective, functional, and radiographic outcomes of plantar plate repair (PPR) from a dorsal approach. METHODS: A prospective case series was performed evaluating the results of PPR in 97 feet with 138 plantar plate tears. Patients underwent PPR from a dorsal approach with a Weil osteotomy. We followed patients at regular intervals for 12 months and collected data preoperatively and postoperatively with respect to visual analog scale (VAS) scores, MTP range of motion (ROM), paper pull-out test, American Orthopaedic Foot & Ankle Society (AOFAS) scores, satisfaction, and radiographic measures. RESULTS: Eighty percent of patients scored "good" to "excellent" satisfaction scores at 12 months. The mean VAS pain score preoperatively was 5.4/10, and postoperatively was 1.5/10. The mean AOFAS scores increased from 49 to 81 points following surgery. The mean MTP ROM preoperatively was 43 degrees and postoperatively 31 degrees. Forty-two percent of toes passed the paper pull out test prior to surgery and 54% at 12 months. Mean metatarsal shortening was 2.4/3.1/1.2 mm for the second, third, and fourth metatarsals, respectively. The mean MTP joint angles preoperatively were 2/4.9/-1.3 degrees and postoperatively were 7.4/9.6/0.2 degrees, respectively, for the second, third, and fourth MTP joints. CONCLUSION: We found that the plantar plate could be repaired through a dorsal approach with reliable outcomes. PPR was a viable option to anatomically restore the ligamentous support in the unstable lesser MTP joint. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Metatarsophalangeal joint pathology in crossover second toe deformity: a cadaveric study.

BACKGROUND: Ligamentous and capsular insufficiency of the second metatarsophalangeal joint has been surgically treated for over two decades, mainly with indirect surgical repairs, which stabilize adjacent soft tissue and shorten or decompress the osseous structures. While ligamentous insufficiency has been described and recognized, degeneration of the plantar plate and tears of the capsule have rarely been documented. The purpose of this study was to document and describe the presence and pattern of plantar plate tears in specimens with crossover second toe deformities, and based on this, to develop an anatomical grading system to assist in the assessment and treatment of this condition. METHODS: Sixteen below-knee cadaveric specimens with a clinical diagnosis of a second crossover toe deformity were examined, and dissected by removing the metatarsal head. The pathologic findings of plantar plate and capsular pathology, as well as ligamentous disruption, were observed and recorded. Demographics of the specimens were recorded, and simulated weightbearing radiographs were obtained prior to dissection so that pertinent angular measurements could be obtained. RESULTS: Demographics demonstrated a high percentage of female specimens, and a typically older population that has been reported for this condition. Radiographic findings documented a high percentage of hallux valgus and hallux rigidus deformities. The MTP-2 and MTP-3 angles were divergent consistent with a crossover toe deformity. We consistently found transverse tears in the plantar plate region immediately proximal to the capsular insertion on the base of the proximal phalanx. With increasing deformity, wider distal transverse tears extending from lateral to medial were found. Midsubstance tears, collateral ligament tears, and complete disruption of the plantar plate were found in more severe deformities. CONCLUSION: In this largest series of cadaveric dissections of crossover second toe deformities, we describe the types and extent of plantar plate tears associated with increasing deformity of the second ray. We present, based on these findings, an anatomic grading system to describe the progressive anatomic changes in the plantar plate.

Turf toe: soft tissue and osteocartilaginous injury to the first metatarsophalangeal joint.

The use of artificial turf in the United States has created a dramatic increase in first metatarsophalangeal joint dorsiflexion injuries. Turf toe has been reported to occur in athletes who participate in sporting activities. An injury to the plantar capsular ligamentous complex can result in acute and chronic pain, resulting in time lost from sports participation for a short- or long-term period. Classification of this injury is based on clinical findings and imaging studies, including plain radiographs and magnetic resonance imaging. The early recognition of this injury is crucial to successful treatment. Nonoperative treatment may often suffice for incomplete injuries; however, surgery may be warranted for a complete plantar plate disruption or injury to one or both sesamoids. In the high-performance or elite athlete, a turf toe or severe dorsiflexion injury can be disabling, and can threaten an athlete's career if not treated properly.

Calcium pyrophosphate dihydrate deposition disease (pseudogout) after total knee arthroplasty.

The authors report a case of calcium pyrophosphate dihydrate deposition disease (pseudogout) presenting in the early period after primary total knee arthroplasty. The patient's symptoms resolved with conservative management including colchicine and indomethacin. The presentation of pseudogout resembles septic arthritis and should be included in the differential diagnosis to prevent unnecessary surgery in these patients.

Chronic plantar fasciitis: acute changes in the heel after extracorporeal high-energy shock wave therapy--observations at MR imaging.

PURPOSE: To prospectively evaluate with magnetic resonance (MR) imaging the acute changes in the heel associated with extracorporeal shock wave therapy (ESWT). MATERIALS AND METHODS: Institutional clinical study review board approved the study, and informed consent was obtained. MR imaging was performed within 24 hours before and after ESWT on 18 feet of 12 patients (eight women and four men; age range, 33-63 years; average, 49.9 years) with chronic plantar fasciitis. ESWT was applied to the most painful point on the plantar surface of the heel, with a total of 1500 shocks at 18 kV. The MR imaging protocol consisted of sagittal and coronal T1- and T2-weighted images with and without fat saturation. The images were reviewed to assess the post-ESWT changes in soft-tissue and bone marrow edema, the thickness of the proximal plantar fascia, and the presence of a heel spur. Paired t test was used for the statistical analysis. RESULTS: Soft-tissue edema, which was present in 16 (89%) of 18 heels before ESWT, had increased in severity in 12 (75%) heels after ESWT. Calcaneus bone marrow edema at the insertion site was observed in eight heels before ESWT. After ESWT, the extant of bone marrow edema had increased in one heel and had newly developed in another heel. The heel spur seen in nine (50%) feet was not affected by ESWT. In 17 (94%) heels, the proximal plantar fascia was abnormally thick, with thickness not significantly changed with use of ESWT (P > .05). CONCLUSION: Increase in soft-tissue edema is the most common acute response associated with ESWT.

Plantarflexion opening wedge medial cuneiform osteotomy for correction of fixed forefoot varus associated with flatfoot deformity.

BACKGROUND: Flatfoot presents as a wide spectrum of foot deformities that include varying degrees of hindfoot valgus, forefoot abduction, and forefoot varus. Medial displacement calcaneal osteotomy, lateral column lengthening, and subtalar fusion can correct heel valgus, but may not adequately correct the fixed forefoot varus component. The purpose of this study was to determine the effectiveness of plantarflexion opening wedge medial cuneiform (Cotton) osteotomy in the correction of forefoot varus. METHODS: Sixteen feet (15 patients) had plantarflexion opening wedge medial cuneiform osteotomies to correct forefoot varus associated with flatfoot deformities from several etiologies, including congenital flatfoot (six feet, average age 37 years), tarsal coalition (five feet, average age 15 years), overcorrected clubfoot deformity (two feet, ages 17 years and 18 years), skewfoot (one foot, age 15 years), chronic posterior tibial tendon insufficiency (one foot, 41 years), and rheumatoid arthritis (one foot, age 56 years). RESULTS: Standing radiographs showed an average improvement in the anterior-posterior talo-first metatarsal angle of 7 degrees (9 degrees preoperative, 2 degrees postoperative). The talonavicular coverage angle improved an average of 15 degrees (20 degrees preoperative, 5 degrees postoperative). The lateral talo-first metatarsal angle improved an average of 14 degrees (-13 degrees preoperative, 1 degree postoperative). Correcting for radiographic magnification, the distance from the mid-medial cuneiform to the floor on the lateral radiograph averaged 40 mm preoperatively and 47 mm postoperatively (average improvement 7 mm). All patients at followup described mild to no pain with ambulation. There were no nonunions or malunions. CONCLUSIONS: Opening wedge medial cuneiform osteotomy is an important adjunctive procedure to correct the forefoot varus component of a flatfoot deformity. Advantages of this technique in comparison to first tarsometatarsal arthrodesis include predictable union, preservation of first ray mobility, and the ability to easily vary the amount of correction. Because of the variety of hindfoot procedures done in these patients, the degree of hindfoot correction contributed by the cuneiform osteotomy alone could not be determined. We have had excellent results without major complications using this technique.

Peripheral nerve entrapments.

Peripheral nerve entrapment is a rare, but important, cause of foot and ankle pain that often is underdiagnosed and mistreated. A peripheral nerve may become entrapped anywhere along its course, but certain anatomic locations are characteristic. Clinically,nerve entrapment is divided into three stages: in stage I patients feel rest pain and intermittent paresthesias which are worse at night; in stage II, continued nerve compression leads to paresthesias, numbness, and, occasionally, muscle weakness that does not disappear during the day, and in stage III, patients describe constant pain, muscle atrophy, and permanent sensory loss. Diagnostic confusion abounds because of the multiple etiologies of peripheral nerve entrapments and their complex physical and temporal relation. A thorough understanding of the causes of peripheral nerve entrapments, the anatomic course and variation of the peripheral nerves, the diagnostic modalities, and the treatment options can simplify this complex problem.