Did Failure Occur Because of Medial Column Instability That Was Not Recognized, or Did It Develop After Surgery?

Medial column instability is a primary deforming force in the setting of pes planovalgus deformity. Consideration for medial column stabilization only after correction of the hindfoot deformity may result in creating a rigid hindfoot, compromising clinical outcomes. Careful analysis of the lateral radiograph to determine whether the deformity is secondary to the medial column or true peritalar subluxation may allow superior outcomes. Iatrogenic creation of an excessively rigid medial column may lead to significant instability of the remaining joints in the short term and arthrosis in the long term. Medial column arthrodesis should be used selectively to correct gross instability.

Treatment of Foot and Ankle Neuroma Pain With Processed Nerve Allografts.

BACKGROUND: Localized nerve pain in the foot and ankle can be a chronic source of disability after trauma and has been identified as the most common complication following operative interventions in the foot and ankle. The superficial location of the injured nerves and lack of suitable tissue for nerve implantation make this pain refractory to conventional methods of neuroma management. We describe a novel strategy for management using processed nerve allografts to bridge nerve gaps created by resection of both end neuromas and neuromas-in-continuity. METHODS: A retrospective review of a prospectively maintained database was performed of all patients who received a processed nerve allograft for treatment of painful neuromas in the foot and ankle between May 2010 and June 2015. Patient demographic and operative information was obtained, as well as preoperative and postoperative pain assessments using a conventional ordinal scale and PROMIS (Patient Reported Outcomes Measurement Information System) Pain Behavior and Pain Interference assessments. Twenty-two patients were identified, with postoperative pain assessments occurring at a mean of 15.5 months after surgery. RESULTS: Neuromas of the sural and superficial peroneal nerves were the most common diagnoses, with 3-cm nerve allografts being used as the interposition graft in the majority of cases. Eight patients had end neuromas and 18 patients had neuromas in continuity. Analysis of paired data demonstrated a mean ordinal pain score decrease of 2.6, with 24 and 31 percentage-point decreases in PROMIS Pain Behavior and Pain Interference measures, respectively. All changes were significant (P < .002). CONCLUSION: The painful sequelae of superficial nerve injuries in the foot and ankle was significantly improved with complete excision of the involved nerve segment followed by bridging of the resulting nerve gap with a processed nerve allograft. This approach limits surgery to the site of injury and reconstitutes the peripheral nerve anatomy. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Effect of Arthroscopic Evaluation of Acute Ankle Fractures on PROMIS Intermediate-Term Functional Outcomes.

BACKGROUND: Following open reduction internal fixation (ORIF) of unstable ankle fractures, some patients have persistent pain and poor outcomes. This may be secondary to intra-articular injuries that occur at the time of fracture, which occur in up to 88% of fractures. Ankle arthroscopy at the time of ORIF has been proposed to address these intra-articular injuries. This study compared patient-reported functional outcomes in patients who underwent ankle ORIF with and without ankle arthroscopy. METHODS: An institutional database was used to retrospectively identify 93 patients who underwent ORIF for an unstable ankle fracture with an intact medial malleolus between 2002 and 2013. Forty-two patients had ankle arthroscopy at the time of ORIF and 51 did not. Functional outcomes between groups were compared using Patient Reported Outcomes Measurement Information System (PROMIS) physical function and pain interference computerized adaptive tests at a minimum follow-up of 1 year. Outcomes were also measured with the visual analog scale (VAS) pain score and the Olerud and Molander ankle fracture outcome scale. Average patient follow-up was 67 months (n = 51). RESULTS: PROMIS physical function and pain interference scores were not significantly different between groups (physical function, 57.8 vs. 54.5, P = .23; pain interference, 45.6 vs. 46.9, P = .56). Operative time was increased in the arthroscopy group (74 minutes vs. 59 minutes, P = .027). Overall, 60% (25/42) had chondral lesions of the talus, 7% (3/42) had chondral lesions of the tibial plafond, and 21% (9/42) had loose bodies requiring removal. There was no significant difference in complication rates between groups. CONCLUSION: At intermediate-term follow-up of patients with unstable ankle fractures and intact medial malleoli, functional outcomes were not significantly improved in patients who underwent ankle arthroscopy. However, there were no increased complications attributable to ankle arthroscopy, and average total operative time was increased by only 15 minutes. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Prevalence of and factors associated with posterior tibial tendon pathology on sonographic assessment.

OBJECTIVE: To assess the frequency of and factors associated with supramalleolar posterior tibial tendon (PTT) pathology that often may be missed on sonography because of the limited field of view of ultrasound. DESIGN: Retrospective cross-sectional study. SETTING: Large academic center. PATIENTS: Patients with medial ankle pain and tenderness and with normal radiographs who presented for sonographic assessment (n = 217). METHODS: Two experienced musculoskeletal radiologists interpreted the studies by consensus. MAIN OUTCOME MEASUREMENT: PTT pathology. RESULTS: Of the 217 patients, 33.2% had grade 1 PTT pathology (n = 72), 14.3% had grade 2 pathology (n = 31), and 2.8% had grade 3 pathology (n = 6). When stratified by location, 29.0% of patients (n = 63) had inframalleolar abnormalities, 11.5% had retromalleolar pathology (n = 25), and 11 patients had supramalleolar pathology (5.1%). Four patients had PTT subluxation or dislocation. Age was significantly associated with PTT pathology (P = .02). A higher proportion of patients with supramalleolar (81.8%) and retromalleolar (72.0%) PTT pathology were women compared with patients who had inframalleolar (57.1%) PTT pathology. A higher proportion of patients with supramalleolar and retromalleolar PTT pathology had grade 2 tears compared with those with inframalleolar PTT pathology (36.4% for supramalleolar, 44.0% for retromalleolar, and 22.2% for inframalleolar pathology). CONCLUSIONS: We present one of the largest studies on PTT pathology. PTT pathology can occur in the supramalleolar area, a region that often is not assessed on imaging. Although data are unavailable with regard to whether the natural history of supramalleolar PTT is different from that of other regions, patients with supramalleolar PTT pathology had more severe grades of tear and increased prevalence of tenosynovitis and were more often women. It is essential to recognize supramalleolar PTT pathology so that consequences of nontreatment such as medial arch collapse can be prevented.

Fresh osteochondral allograft for the treatment of cartilage defects of the talus: a retrospective review.

BACKGROUND: Osteochondral lesions of the talar dome can cause substantial functional impairment and present a difficult treatment dilemma. Interest has recently focused on fresh osteochondral allografts as a promising treatment alternative. The purpose of this study was to evaluate the clinical outcome of osteochondral lesions of the talus treated with a fresh osteochondral allograft. METHODS: We performed a transfer of fresh osteochondral allograft in forty-two patients with a symptomatic, refractory osteochondral lesion of the talus. Complete postoperative follow-up was achieved for thirty-eight patients with an average age of 44.2 years. Clinical evaluation was performed with use of the American Orthopaedic Foot & Ankle Society ankle-hindfoot score and a visual analog pain scale. All scores were obtained from either a retrospective chart review or a direct patient interview. All patients were also asked about their subjective satisfaction with the procedure. Magnetic resonance images were acquired for fifteen patients, to assess graft incorporation, subsidence, articular cartilage congruity, osteoarthritis, and stability with use of the De Smet criteria. RESULTS: The average duration of follow-up after osteochondral allograft transplantation was 37.7 months. Graft failure occurred in four patients. With the inclusion of scores before revision for those with graft failure, the mean visual analog pain scale score improved from 8.2 to 3.3 points, and the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot score improved from 52 to 79 points. Patient satisfaction with the outcome was rated as excellent, very good, or good by twenty-eight of the thirty-eight patients and as fair or poor by ten patients. Of the fifteen magnetic resonance imaging scans, most showed minimal graft subsidence, reasonable graft stability, and persistent articular congruence. CONCLUSIONS: In our experience, transplantation of fresh osteochondral allograft is a viable and effective method for the treatment of osteochondral lesions of the talus as evidenced by improvements in pain and function.

Nerve stimulator-guided supplemental popliteal sciatic nerve block after a failed sciatic block does not increase the incidence of transient postoperative neurologic sequelae.

BACKGROUND: Supplemental peripheral nerve blocks are not commonly performed in adults because of concerns of cumulative exposure of the nerve to the local anesthetic as well as increased ischemia from epinephrine. The purpose of this study was to compare the incidence of postoperative neurologic symptoms after a failed subgluteal sciatic nerve block and a supplemental popliteal sciatic nerve block. METHODS: Five hundred twelve adult patients undergoing ambulatory surgery were prospectively studied (1 yr). Sciatic nerve blocks were performed using levobupivacaine 0.625% with epinephrine 1:200,000 (0.5 ml/kg). Patients who failed to achieve sensory and motor anesthesia at 30-60 min were given a popliteal sciatic nerve block (lidocaine 2% 10 ml + levobupivacaine 0.5% 10 ml). Subjects were contacted at 24 h to 48 h, 2 weeks, and 1 month. Symptomatic patients were contacted biweekly and reevaluated during follow-up surgeon visits until symptom resolution. RESULTS: Four hundred thirty-nine subjects were analyzed. Fifty-six received a popliteal sciatic nerve block. Four subjects (0.9%) had self-reported neurologic symptoms in the distribution of the sciatic nerve. Investigator-initiated follow-up revealed 33 subjects (8.7%) who received a single subgluteal sciatic block and 4 subjects (7.1%) after a supplemental sciatic nerve block with neurologic symptoms (P = 0.80). The median duration of symptoms was 4 weeks (95% CI 3-5) in the subgluteal and 4 weeks (95% CI 3-5) weeks in the popliteal group (P = 0.98). All symptoms resolved by 14 weeks postprocedure. CONCLUSION: Blocking the sciatic nerve at a more distal site after a failed subgluteal sciatic nerve block does not appear to influence the incidence or duration of neurologic sequelae.

Ultrasound diagnosis of peroneal tendon tears. A surgical correlation.

BACKGROUND: Musculoskeletal ultrasound is an established diagnostic technique for the assessment of tendon injuries. The purpose of the present study was to determine whether ultrasound is effective for evaluating peroneal tendon injuries, with surgical findings used as the standard of reference. METHODS: Fifty-eight patients with a suspected peroneal tendon injury were prospectively evaluated with use of dynamic ultrasound. Twenty-five patients were found to have peroneal tendon tears and were managed operatively. Five patients with normal peroneal tendons on ultrasound examination also were managed operatively for other reasons and are included in the series as the peroneal tendons were inspected at the time of the procedure. Ultrasound and surgical criteria were used to grade the peroneal tendons on a scale from grade 0 (normal tendon) to grade III (tendon rupture). RESULTS: Of the sixty tendons that were evaluated operatively, twenty-five were found to be torn. The sensitivity, specificity, and accuracy of ultrasonography were 100%, 85%, and 90%, respectively. CONCLUSIONS: The use of dynamic ultrasound is effective for determining the presence or absence of a peroneal tendon tear and should be considered a first-line diagnostic tool.

Plantar forefoot pressure changes after second metatarsal neck osteotomy.

BACKGROUND: The aim of this study was to evaluate plantar pressure changes after second metatarsal neck osteotomy using the Weil technique. METHODS: Six below-knee cadaver specimens were used. Each specimen was held in a custom-built apparatus and loaded to 500 N for a period of 3 seconds. Using a computerized Musgrave pedobarograph, pressure measurements were made before and after osteotomy in both neutral and 45-degree heel rise positions. All osteotomies were made at an angle of approximately 20 degrees relative to the long axis of the metatarsal shaft. The metatarsal heads were displaced proximally by 5 mm and fixed with a single Kirschner wire. RESULTS: After osteotomy there was an average decrease in pressure beneath the second metatarsal from 70.6 to 45.1 kPa in neutral and from 813.0 to 281.4 kPa in heel rise, representing statistically significant (p < or = 0.05) decreases of 36% and 65%, respectively. There also were significant decreases beneath the third metatarsal in both neutral (39%) and heel rise (37%), and beneath the fourth metatarsal in neutral position (28%). A significant pressure increase occurred beneath the first metatarsal in neutral (23%). No significant pressure changes occurred under the fifth metatarsal in either position. CONCLUSION: Overall, our results indicated that the Weil metatarsal neck osteotomy is effective at offloading the second metatarsal head at neutral and heel rise positions.

Technical considerations in hallux metatarsalphalangeal arthrodesis.

Metatarsalphalangeal (MTP) arthrodesis remains the gold standard for arthritis and salvage of the painful first MTP joint. There is a variety of techniques, approaches, and armamentarium to consider, depending on the clinical presentation and host factors. This article reviews these presents the author's personal experience.