Dorsal calcaneal wedge removal in zadek osteotomy: A cadaveric study.

BACKGROUND: Insertional Achilles tendinopathy (IAT) is a common pathology with multiple surgical interventions available for treatment. The Zadek, dorsal closing wedge calcaneal osteotomy (ZO) has been demonstrated to be effective treatment of IAT. There have been various recommendations in the literature as to what measurement of wedge removal should be considered ideal to produce greatest postoperative range of motion (ROM), thus postoperative biomechanical potential. Accordingly, the purpose of this cadaveric study was to assess the range of motion achieved after various measurements of wedge removal by ZO. METHODS: The ZO was performed on six cadaveric specimens. A 7.5 mm and 15 mm wedge osteotomy was marked and sequentially completed on each specimen. Lateral fluoroscopic imaging was utilized to take preoperative and postoperative ROM measurements for each osteotomy. Dorsiflexion (DF) and plantarflexion (PF) ROM arcs were measured for each wedge size and compared by t-test. Effect sizes were calculated by Cohen's d analysis. RESULTS: Maximal DF was 110.87 ± 12.97 deg in the pre-osteotomy state. Removal of a 7.5 mm wedge improved DF by 8 deg to a mean 102.93 ± 13.81 deg (p = 0.08). Removal of a 15 mm wedge improved DF by 16 deg to a mean 95.96 ± 11.41 deg (p = 0.003). Cohen's d and effect size calculation demonstrated a 7.5 mm wedge to have a small effect on DF, while a 15 mm wedge had a medium effect (0.29, 0.52 respectively). Maximal PF did not change significantly amongst the pre-osteotomy, 7.5 mm wedge, or 15 mm wedge positions. ICC was 0.96. CONCLUSION: Based on the results presented in this study, removal of a 15 mm wedge with ZO yields significant and greater improvement in ROM than a 7.5 mm wedge. We hope the current study will better inform preoperative planning for ZO. STUDY TYPE: Prospective Cadaver Study. LEVEL OF EVIDENCE: V.

Percutaneous vs Open Zadek Osteotomy for Treatment of Insertional Achilles Tendinopathy and Haglund's Deformity: A Systematic Review.

Background: Percutaneous Zadek osteotomy (ZO) has emerged as a surgical treatment of insertional Achilles tendinopathy (IAT) over the last decade. Existing literature is limited regarding the comparison of this approach with the more established, open ZO technique. This systematic review aims to evaluate and compare the current data on open vs percutaneous ZO approaches to help set evidence-based guidelines. Methods: A systematic literature search was performed using the keywords (Zadek osteotomy) OR (Keck and Kelly osteotomy) OR (dorsal closing wedge calcaneal osteotomy) OR (Haglund Deformity) OR (Haglund Syndrome) OR (Insertional Achilles Tendinopathy) and MeSH terms Osteotomy, Calcaneus, Syndrome, Insertional, Achilles tendon, and Tendinopathy. Our search included the following databases: PubMed, Embase, and the Cochrane Library. The PRISMA protocol and the Cochrane Handbook guidelines were followed. All studies included were published from 2009 to 2024 and included the use of open or percutaneous approaches of ZO for the treatment of IAT with at least a 12-month follow-up. The MINORS score criteria were used to evaluate the strength and quality of studies. Results: A total of 17 studies were reviewed, including 611 subjects and 625 ZO procedures. Of these procedures, 81 (11%) subjects had a percutaneous and 544 (89%) subjects had an open ZO. The mean follow-up time was 16.1 months for patients treated with percutaneous ZO and 36.1 months for patients treated with open ZO. Both open and percutaneous studies included in this review showed postoperative improvements in AOFAS, FFI, VISA-A, and VAS scores in patients with IAT. The reported complication rate was 5.8% among patients treated with percutaneous ZO and 10.2% among patients treated with open ZO. Conclusion: Percutaneous ZO is an emerging approach with substantially fewer documented cases compared with the open ZO. Both percutaneous and open ZO appear to be relatively effective treatments for insertional Achilles tendinopathy with Haglund's deformity. The lower complication rates reported for percutaneous ZO is encouraging. Further investigation with more subjects undergoing percutaneous ZO is clearly needed.

Patients With Opioid Use Disorder Have Increased Readmission Rates, Emergency Room Visits, and Costs Following a Hallux Valgus Procedure.

BACKGROUND: Patients with a history of opioid use disorder (OUD) tend to have more complications, higher readmission rates, and increased costs following orthopaedic procedures. This study evaluated patients undergoing hallux valgus correction for their odds of increased (1) readmission rates, (2) emergency room (ER) visits, and (3) costs. METHODS: Patients undergoing hallux valgus corrections with OUD history were identified using a national Medicare administrative claims database of approximately 24 million orthopaedic surgery patients. OUD patients were matched to non-opioid use disorder (NUD) patients in a 1:4 ratio by age, sex, Elixhauser-Comorbidity Index (ECI), diabetes mellitus, hyperlipidemia, hypertension, and tobacco use. The query yielded 6318 patients (OUD = 1276; NUD = 5042) who underwent a hallux valgus correction. Primary outcomes analyzed included odds of 90-day readmission rates, 30-day ER visits, and 90-day episode-of-care costs. Demographics, odds ratios (ORs), ECI, and cost were assessed as appropriate using a Pearson χ2 test, logistic regression, and a t test. A P value <.05 was considered statistically significant. RESULTS: There were no significant differences in demographics between OUD and NUD patients. OUD patients had higher incidence and odds of 90-day readmission (9.56% vs 6.04%; OR = 1.55; P < .001) and 30-day ER visits (0.86% vs 0.35%; OR = 2.42; P = .021) and incurred greater 90-day episode-of-care costs ($7208.28 vs $6134.75; P < .001) compared with NUD patient controls. CONCLUSION: The study demonstrates the possible influence of OUD on higher odds of readmission, ER visits, and costs following a hallux valgus correction. LEVELS OF EVIDENCE: Level III: Retrospective cohort study.

The Influence of Opioid Use Disorder on Open Reduction and Internal Fixation Following Ankle Fracture.

BACKGROUND: Ankle fractures are common and may require open reduction and internal fixation (ORIF). Literature is scarce evaluating the associations of opioid use disorder (OUD) with ORIF postoperative outcomes. This study investigates whether OUD patients have increased (1) costs of care, (2) emergency room visits, and (3) readmission rates. METHODS: ORIF patients with a 90-day history of OUD were identified using an administrative claims database. OUD patients were matched (1:4) to controls by age, sex, and medical comorbidities. The Welch t-test determined the significance of cost of care. Logistic regression yielded odds ratios (ORs) for emergency room visits and 90-day readmission rates. RESULTS: A total of 2183 patients underwent ORIF (n = 485 with OUD vs n = 1698 without OUD). OUD patients incurred significantly higher costs of care compared with controls ($5921.59 vs $5128.22, P < .0001). OUD patients had a higher incidence and odds of emergency room visits compared with controls (3.50% vs 0.64%; OR = 5.57, 95% CI = 2.59-11.97, P < .0001). The 90-day readmission rates were not significantly different between patients with and without OUD (8.65% vs 7.30%; OR = 1.20, 95% CI = 0.83-1.73, P = .320). CONCLUSION: OUD patients have greater costs of care and odds of emergency room visits within 90 days following ORIF.Levels of Evidence: Level III: Retrospective cohort study.

Unifying the Orthopaedic Surgery Residency Application Process Under a Single Accreditation System: A Primer.

In 2020, the Accreditation Council for Graduate Medical Education and the American Osteopathic Association will merge creating a single accreditation system for graduate medical education in the United States under the National Residency Match Program. The goal of this merger is to ensure nationwide consistency in purpose and practice of medical care in the United States, specifically in the context of residency education and training for the next generation of physicians. The proposed impact is still speculative since we do not know what lasting effects, if any, this merger will have on subspecialties such as orthopaedic surgery. There are many considerations that medical school advisors need to take into account when guiding their students applying to residency after the match merge. The newly unified accreditation system will pose additional competition, considering that there will be more applicants than spots available in competitive specialties, including orthopaedic surgery. These are important caveats to keep in mind as the residency application process is evolving actively. It is the authors' hope that concepts discussed in this article stimulate further discussion, catalyze research, and optimize the ability for students to succeed in the match process.

A Modification of the Fibular Osteotomy for Total Ankle Replacement Through the Lateral Transfibular Approach.

BACKGROUND: One disadvantage of lateral transfibular total ankle arthroplasty is the rate of symptoms related to the implant and wound issues requiring implant removal in association with the traditional fibular osteotomy. In the present study, lateral total ankle arthroplasty involving the traditional short oblique fibular osteotomy was compared with arthroplasty involving a long oblique osteotomy (the Foot & Ankle Reconstruction Group osteotomy). METHODS: We retrospectively reviewed all primary lateral total ankle arthroplasties that had been performed by a single surgeon from May 2013 to October 2016 and had a minimum of 2 years of follow-up. Clinical assessment included patient demographics, wound complications, the need for implant removal, the pain score on a visual analog scale, the American Orthopaedic Foot & Ankle Society score, and the Short Form-12 Mental and Physical Component Summary scores. Weight-bearing radiographs were used to assess tibiotalar alignment, implant alignment, and fibular osteotomy healing. RESULTS: One hundred and fifty-nine total ankle arthroplasties were identified. The traditional short fibular osteotomy was used in 50 ankles, and the long oblique osteotomy was used in 109. The rate of survival of the tibial and talar components of the ankle replacements was 100%, and there were no osteotomy nonunions. There was improvement in all clinical parameters, with no significant difference between the 2 groups. Radiographs showed excellent arthroplasty alignment at all time points, with no significant difference between the groups. There was a significant difference in the rates of wound dehiscence (p = 0.011) and fibular implant removal (p < 0.0001), with the long oblique osteotomy having lower rates of both (2.8% and 2.8%, respectively) compared with the short oblique osteotomy (14% and 28%, respectively). CONCLUSIONS: In total ankle arthroplasty, modification of the traditional short oblique fibular osteotomy to a long oblique configuration provided excellent 2-year survival rates with good clinical and radiographic outcomes and decreased rates of wound complications and symptoms related to the fibular implant. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Should Routine Methicillin-Resistant Staphylococcus aureus (S. aureus), or MRSA, Screening Be in Place Prior to Total Ankle Arthroplasty (TAA)?

RECOMMENDATION: Unknown. The role of screening for methicillin-resistant Staphylococcus aureus (MRSA) and decolonization prior to total ankle arthroplasty (TAA) remains unclear. Further data are needed to support this practice in TAA, which can be costly and logistically difficult to implement. LEVEL OF EVIDENCE: Consensus. DELEGATE VOTE: Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Management of Isolated Lateral Malleolus Fractures.

Isolated lateral malleolus fractures represent one of the most common injuries encountered by orthopaedic surgeons. Nevertheless, appropriate diagnosis and management of these injuries are not clearly understood. Ankle stability is maintained by ligamentous and bony anatomy. The deep deltoid ligament is considered the primary stabilizer of the ankle. In the setting of an isolated lateral malleolus fracture, identifying injury to this ligament and associated ankle instability influences management. The most effective methods for assessing tibiotalar instability include stress and weight-bearing radiographs. Clinical examination findings are important but less reliable. Advanced imaging may not be accurate for guiding management. If the ankle is stable, nonsurgical management produces excellent outcomes. In the case that clinical/radiographic findings are indicative of ankle instability, surgical fixation options include lateral or posterolateral plating or intramedullary fixation. Locking plates and small or minifragment fixation are important adjuncts for the surgeon to consider based on individual patient needs.

The Failed Cavovarus Foot: What Went Wrong and Why?

The adult cavovarus foot exists on a spectrum and, therefore, requires a thorough evaluation to determine the extent of the deformity and then choose from a multitude of surgical procedures to achieve correction. Regardless of the severity of the deformity, treatment should include an algorithmic approach to adequately achieve a stable, balanced, and plantigrade foot. To prevent failure, the surgeon should evaluate whether the deformity is flexible or rigid, determine the location of the apex or apices of the deformity, evaluate any muscle imbalances occurring about the foot and ankle, and determine the need for additional procedures. A failure to consider these principles and, subsequently, the extent of the deformity often results in recurrence and progression of the deformity.