Biologic Augmentation of Tibiotalocalcaneal Arthrodesis With Allogeneic Bone Block Is Associated With High Rates of Fusion.

BACKGROUND: The orthopaedic conditions and systemic comorbidities that occur in patients who require bone block tibiotalocalcaneal (TTC) arthrodesis have made this procedure associated with a higher-than-normal risk of nonunion, graft collapse, hardware failure, and amputation. Here, we present a novel approach to bone block TTC arthrodesis using adjunctive osteoinductive agents and a prolonged course of protected weightbearing to assess if we could improve on historical outcomes. We also evaluated the efficacy of a vascularized medial femoral condyle (MFC) free flap to augment TTC arthrodesis. METHODS: Fourteen adult patients underwent bone block TTC arthrodesis biologically augmented with fresh-frozen femoral head allograft, bone marrow aspirate concentrate, and demineralized bone matrix cortical fibers. Three patients with soft tissue defects underwent vascularized reconstruction with an MFC free flap. Radiographic union, the Foot Function Index (FFI), and PROMIS pain interference (PI), and physical function (PF) scores were assessed at follow-up. RESULTS: TTC fusion was documented on plain radiograph in 13 of 14 patients (92.9%) and CT in 10 of 11 patients (90.9%). Mean time to fusion was 183.2 ± 83.2 days. One patient (7.1%) experienced nonunion and persistent infection requiring amputation. Patients who underwent vascularized bone grafting had significantly shorter time to fusion (112.3 ± 31.7 days vs 204.4 ± 82.7 days, P = .05). Patient-reported outcomes revealed mild to moderate pain and dysfunction after 1 year (mean FFI = 41.0% ± 23.1%, PROMIS PI = 58.3 ± 1.8, PROMIS PF = 39.0 ± 2.2). CONCLUSION: In this relatively small series, the biologic augmentation of bone block TTC arthrodesis with osteoinductive agents and protective weightbearing resulted in excellent rates of fusion, modest pain, and preserved function of the lower extremity in almost all those treated. Osseous healing appears to be enhanced and accelerated with application of an MFC flap. We believe that this approach offers a viable salvage option for these challenging clinical problems. LEVEL OF EVIDENCE: Level IV, case series.

Radiographic analysis of specific morphometrics and patient-reported outcomes (PROMIS) for surgical repair of zones 2 and 3 fifth metatarsal fractures.

BACKGROUND: Zones 2 and 3 fifth metatarsal fractures are often treated with intramedullary fixation due to an increased risk of nonunion. A previous 3-dimensional (3D) computerized tomography (CT) imaging study by our group determined that the screw should stop short of the bow of the metatarsal and be larger than the commonly used 4.5 millimeter (mm) screw. This study determines how these guidelines translate to operative outcomes, measured using Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) surveys. Radiographic variables measuring the height of the medial longitudinal arch and degree of metatarsus adductus were also obtained to determine if these measurements had any effect on outcomes. And lastly, this study aimed to determine if morphologic differences between males and females affected surgical outcomes. METHODS: We retrospectively identified 23 patients (14 male, 9 female) who met inclusion criteria. Eighteen patients completed PROMIS surveys. Preoperative PROMIS surveys were completed prior to surgery, rather than retroactively. Weightbearing radiographs were also obtained preoperatively to assist with surgical planning and postoperatively to assess interval healing. Correlation coefficients were calculated between PROMIS scores and repair characteristics (hardware characteristics [screw length and diameter] and radiographic measurements of specific morphometric features). T tests determined the relationship between repair characteristics, PROMIS scores, and incidence of operative complications. PROMIS scores and correlation coefficients were also stratified by gender. RESULTS: The average screw length and diameter adhered to guidelines from our previous study. Preoperatively, mean PROMIS PI = 57.26±11.03 and PROMIS PF = 42.27±15.45 after injury. Postoperatively, PROMIS PI = 44.15±7.36 and PROMIS PF = 57.22±10.93. Patients with complications had significantly worse postoperative PROMIS PF scores (p=0.0151) and PROMIS PI scores (p=0.003) compared to patients without complications. Females had non-significantly worse preoperative and postoperative PROMIS scores compared to males and had a higher complication rate (33 percent versus 21 percent, respectively). Metatarsus adductus angle was shown to exhibit a significant moderate inverse relationship with postoperative PROMIS PF scores in the overall cohort (r=-0.478; p=0.045). Metatarsus adductus angle (r=-0.606; p=0.008), lateral talo-1st metatarsal angle (r=-0.592; p=0.01), and medial cuneiform height (r=-0.529; p=0.024) demonstrated significant inverse relationships with change in PROMIS PF scores for the overall cohort. Within the male subcohort, significant relationships were found between the change in PROMIS PF and metatarsus adductus angle (r=-0.7526; p=0.005), lateral talo-1st metatarsal angle (r=-0.7539; p=0.005), and medial cuneiform height (r=-0.627; p=0.029). CONCLUSION: Patients treated according to guidelines from our prior study achieved satisfactory patient reported and radiographic outcomes. Screws larger than 4.5mm did not lead to hardware complications, including screw failure, iatrogenic fractures, or cortical blowouts. Females had non-significantly lower preoperative and postoperative PROMIS scores and were more likely to suffer complications compared to males. Patients with complications, higher arched feet, or greater metatarsus adductus angles had worse functional outcomes. Future studies should better characterize whether patients with excessive lateral column loading benefit from an off-loading cavus orthotic or plantar-lateral plating.

Patient-Reported Outcomes and Radiographic Assessment in Primary and Revision Stage II, III, and IV Progressive Collapsing Foot Deformity Surgery.

BACKGROUND: Progressive collapsing foot deformity (PCFD) is a progressive hindfoot and midfoot deformity causing pain and disability. Although operative treatment is stage dependent, few studies have looked at patient-reported and radiographic outcomes stratified by primary vs revision stage II, III, and IV reconstruction surgery. Our goal was to assess operative improvement using Patient-Reported Outcomes Measurement Information System (PROMIS) and to determine whether radiographic parameter improvement correlates with patient-reported outcomes. METHODS: PROMIS Physical Function (PF) and Pain Interference (PI) scores were prospectively obtained on 46 consecutive patients who underwent PCFD reconstruction between November 2013 and January 2019. Thirty-six patients completed pre- and postoperative PROMIS surveys, 6 patients completed only preoperative PROMIS surveys, and 4 patients completed 12-month postoperative PROMIS surveys but did not complete preoperative PROMIS surveys. Minimum follow-up was 12 (average, 23) months. Radiographic correction was measured with pre- and postoperative weightbearing radiographs and correlated with PROMIS scores. Measurements included the talonavicular uncoverage angle, talonavicular uncoverage percentage, anteroposterior talo-first metatarsal angle, Meary angle, medial cuneiform height (MCH), and medial cuneiform-fifth metatarsal height. RESULTS: For the overall cohort, PROMIS PF increased significantly from 37.5±5.6 to 42.3±7.1 (P = .0014). PROMIS PI improved significantly from 64.5±6.0 to 55.1±9.8 (P < .0001). Preoperative, postoperative, and change in PROMIS scores were not statistically different between PCFD stages. Change in PROMIS PI was significantly greater in primary (-12.3) vs revision (-3.7) surgery (P = .0157). Change in PROMIS PF was greater in primary (+6.0) vs revision surgery (+2.3) but did not reach statistical significance. All radiographic measurements improved significantly (P < .05). In primary stage II PCFD, postoperative PROMIS scores correlated with postoperative MCH (PF: r = 0.7725, P = .0020; PI: r = -0.5692, P = .0446). CONCLUSION: Patient-reported and radiographic outcomes improved significantly after PCFD reconstruction. We found no significant difference in preoperative, postoperative, or change in PROMIS scores between PCFD stages. However, stage III patients had smaller improvements in PROMIS PF, which we feel may be secondary to change in function after arthrodesis. Primary operations had better patient-reported outcomes compared to revision operations. In primary stage II PCFD, reconstructing the medial arch height correlated significantly with improvement in pain and functionality. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Trends in Leadership Within Orthopedic Foot and Ankle Fellowships.

BACKGROUND: No study in the orthopedic literature has analyzed the demographic characteristics or surgical training of foot and ankle fellowship directors (FDs). Our group sought to illustrate demographic trends among foot and ankle fellowship leaders. METHODS: The American Orthopaedic Foot & Ankle Society (AOFAS) Fellowship Directory for the 2021 to 2022 program year was queried in order to identify all foot and ankle fellowship leaders at programs currently offering positions in the United States and Canada. Data points gathered included age, sex, race/ethnicity, location of surgical training, time since training completion until FD appointment, length in FD role, and individual research H-index. RESULTS: We identified 68 fellowship leaders, which consisted of 48 FDs and 19 co-FDs. Sixty-five individuals (95.6%) were male, and 3 (4.4%) were female. As regards race/ethnicity, 88.2% of the leadership was Caucasian (n = 60), 7.4% was Asian American (n = 5), 1.5% was Hispanic/Latino (n = 1), and 1.5% was African American (n = 1). The average age was 51.5 years, and the calculated mean Scopus H-index was 15.28. The mean duration from fellowship training to fellowship leader position was 11.23 years. CONCLUSION: Leaders within foot and ankle orthopedic surgery are characterized by research prowess and experience, but demographic diversity is lacking. LEVEL OF EVIDENCE: Level III.

Evaluating Prospective Patient-Reported Pain and Function Outcomes After Ankle and Hindfoot Arthrodesis.

BACKGROUND: Hindfoot and ankle fusions are mechanically limiting procedures for patients. However, patient-reported outcomes of these procedures have not been well studied. This study assessed outcomes of hindfoot and ankle fusions by using Patient-Reported Outcome Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) Computer Adaptive Tests (CATs). METHODS: Between 2014 and 2018, 102 patients were prospectively enrolled after presenting to a tertiary care facility for ankle and hindfoot fusions, including tibiotalar, tibiotalocalcaneal, subtalar, and triple arthrodeses. Study participants completed preoperative and 12-month postoperative PF and PI CATs. The differences between mean 12-month postoperative and preoperative PROMIS PF and PI T scores were analyzed with paired t tests. The relationship between the 12-month PF and PI differences for the overall sample and patient factors was examined using multiple regression modeling. RESULTS: The sample had mean age of 57.69 years; 48% were male, and 55% were obese. Patients who underwent ankle and hindfoot arthrodesis had statistically significant improvements from preoperative to 12 months postoperative in mean PF (36.26±7.85 vs 39.38±6.46, P = .03) and PI (61.07±7.75 vs 56.62±9.81, P = .02). Triple arthrodesis saw the greatest increases in physical function (▵PF = 7.22±7.31, P = .01) and reductions in pain (▵PI = -9.17±8.31, P = .01), achieving minimal clinically important difference (MCID). Patients who underwent tibiotalar fusion had significant improvement in physical function (▵PF = 4.18±5.68, P = .04) and pain reduction that approached statistical significance (▵PI = -6.24±8.50, P = .09), achieving MCID. Older age (≥60 years ) was associated with greater improvements in PF (ß = 0.20, P = .07) and PI (ß = -0.29, P = .04). Preoperative PF and PI T scores were significantly associated with the 12-month change in PF and PI T scores, respectively (ß = -0.74, P < .01; ß = -0.61, P < .01). CONCLUSION: Hindfoot and ankle fusions are procedures with favorable patient outcomes leading to increased physical function and decreased pain at 12 months postoperation relative to preoperation. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Low-Energy Lisfranc Injuries: When to Fix and When to Fuse.

Lisfranc injuries can be devastating to the athlete and nonathlete. In the athletic population, minor loss of midfoot stability compromises the high level of function demanded of the lower extremity. The most critical aspect of treatment is identifying the injury and severity of the ligamentous/articular damage. Not all athletes are able to return to their previous level of function. With appropriate treatment, a Lisfranc injury does not mandate the cessation of an athletic career. We focus on the diagnosis and an algorithmic approach to treatment in the athlete discussion the controversy of open reduction and internal fixation versus arthrodesis.

Effect of Leg Length-Evening Device on Perceived Balance in Patients Wearing a Controlled Ankle Motion Boot.

BACKGROUND: Patients are often made weightbearing as tolerated (WBAT) in a controlled ankle motion (CAM) boot for the management of various foot and ankle conditions. The CAM boot causes a leg length discrepancy (LLD) between the booted (longer) and contralateral (shorter) lower extremities. This discrepancy can potentially cause balance problems, undue strain on joints, and discomfort in patients. We hypothesized that a leg length-evening orthotic placed on the plantar aspect of the contralateral shoe improves balance among patients who are WBAT in a CAM boot. METHODS: Patients made WBAT in a CAM boot were randomized to either the leg length-evening orthotic intervention group or to a control group in which patients wore a normal shoe of their choice. Patients were followed for 2 weeks and asked a series of questions pertaining to balance and pain experienced at their knees, hips, and back. Balance was the primary outcome and was scored from 0 (no difficulty with balance) to 10 (great difficulty with balance). Of 107 subjects enrolled and randomized, 95 (88.8%) completed the study, satisfying the a priori sample size requirement of 94 patients. There were no differences in baseline characteristics between groups (P > .05 for each). RESULTS: Intervention patients reported less difficulty with balance than control patients (intention-to-treat analysis: 2.0±1.5 vs 3.2±1.8, P = .001; as-treated analysis: 2.1±1.7 vs 3.0±1.7, P = .009). Intervention and control patients did not differ with respect to pain experienced at their knees, hips, or back, or in a composite total pain score (P > .05 for each). CONCLUSION: This multicenter randomized controlled trial found that adding a limb length-evening orthotic to the plantar aspect of the contralateral shoe in a patient that is WBAT in a CAM boot improved patient-reported self-assessment of balance. The trial was powered to identify a difference in the primary outcome measure of balance and may have been insufficiently powered to identify differences in knee, hip, back, or total pain. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Comparison of Patient-Reported Outcomes for Major Pathologies of the Forefoot, Midfoot, Hindfoot, and Achilles Using PROMIS.

BACKGROUND: Patient-Reported Outcomes Measurement Information System (PROMIS) is a newly developed patient-reported outcome that has been validated for the general foot and ankle population and has been applied to a variety of specific foot and ankle procedures. However, there is little data regarding clinical outcomes of patients at a more intermediate subgroup level. Thus, our study utilized PROMIS to provide normative data on pathologic conditions of the foot and ankle and assess postoperative outcomes based on anatomical location. METHODS: Preoperative and 1-year postoperative PROMIS Physical Function (PF) and Pain Interference (PI) surveys were prospectively collected from a cohort of patients undergoing a foot and ankle procedure at a tertiary medical center. The cohort was split into forefoot (n = 136), midfoot (n = 44), hindfoot (n = 109), and Achilles (n = 62) procedure groups. Paired-t tests were used to compare preoperative versus postoperative outcomes within operative groups, while a 1-way analysis of variance (ANOVA) was used to detect differences in PROMIS scores between anatomic subgroups. RESULTS: Paired t tests indicated that all 4 operative groups had significantly improved PROMIS PF and PI scores preoperatively versus 1 year postoperatively (all P < .001). One-way ANOVA demonstrated that there were no differences in postoperative PROMIS PF and PI scores between anatomic subgroups. A majority of patients achieved the minimal clinically important difference level of improvement in PROMIS PF and PI scores following surgery. CONCLUSIONS: All 4 operative groups had improvement in physical function and pain outcomes. Additionally, there were no differences in physical function and pain outcomes between operative groups. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Minimally Invasive Treatments of Acute Achilles Tendon Ruptures.

Achilles tendon rupture is a common injury to the lower extremity that requires appropriate treatment to minimize functional deficit. Available treatments of Achilles tendon ruptures include nonoperative, open surgical repair, percutaneous repair, and minimally invasive repair. Open surgical repair obtains favorable functional outcomes with significant potential for deep soft tissue complications, calling into question the value of open repair. Percutaneous repair is an alternative option with comparable functional results and minimal soft tissue complications; however, sural nerve injury is a complication. Minimally invasive Achilles repair offers optimal results with superior functional outcomes with minimal soft tissue complications and sural nerve injury.

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.