Incidence of Nonunion of the First Metatarsophalangeal Joint Arthrodesis After Failed Implant Arthroplasty: A Systematic Review.

Joint arthroplasty of the first metatarsophalangeal (MTP) joint is an accepted surgical option for patients with hallux rigidus. However, this procedure has been reported to have a high complication rate and unpredictable survivorship. Implant arthroplasty failure is a devastating complication that results in significant osseous defect with altered biomechanics of the foot. Commonly, salvage options are limited to arthrodesis with bone grafting. However, outcomes are rarely reported. The purpose of this study is to investigate the fusion rates of first metatarsophalangeal joint arthrodesis after conversion from failed implant arthroplasty. A systematic review of electronic databases to find reports of conversion arthrodesis after failed implant arthroplasty was performed. Six studies involving a total of 76 patients with a weighted mean age of 54.9 met the inclusion criteria. Out of the 6 included articles, the nonunion rate was 16.5% at a weighted mean follow-up of 48.1 months. The nonunion rate in the current report is higher than reported nonunion rates of primary arthrodesis. More prospective studies with consistent and standard outcome measures are needed to further determine the success rate of this salvage procedure.Levels of Evidence: 4, Systematic Review of Level 4 Studies.

Triple Arthrodesis: How to Manage Failures, Malunion, and Nonunion.

Nonunions are managed by general principles that govern other bone healing sites; however, when confounding with malunion, additional attention must be given. Malunited triple arthrodesis requires a thorough understanding of biomechanical and surgical principles for adequate revision surgery. Due to the rigid nature of arthrodesis surgery on a weight-bearing surface, malunited fusions have very low patient tolerance. The lack of joints leads to a block of bone that can be corrected via derotational osteotomies with wedge supplementation. However, even if a rectus foot is achieved, compensatory motion via the ankle joint commonly causes arthritic long-term sequelae.

Direct Plantar Approach to Plantar Plate Repair and Associated Wound Complications.

BACKGROUND: Lesser toe metatarsophalangeal joint (MTPJ) instability, secondary to plantar plate tear, has been the focus of numerous recent publications, the majority reporting on repair through a dorsal approach. A plantar approach has been described with the advantage of direct ligamentous repair or repair to bone, which follows conventional techniques employed throughout the body. Previous clinical studies have shown success in deformity correction and the longevity of both approaches. The proponents of the dorsal approach advocate that indirect repair of the plantar plate avoids perceived risks of complications with a plantar incision without evidence of superior outcomes. The purpose of this study was to investigate the safety and efficacy of the direct plantar approach to plantar plate repairs (PPRs) by reporting the rate of specific complications in a large clinical series. METHODS: This was the institutional review board (IRB) approved retrospective study of 204 PPRs in 185 patients (194 lesser MTP, 10 hallux MTP) with an average age of 56 and a mean body mass index (BMI) of 28. Surgical technique involved repair with absorbable braided suture (88%) versus suture anchor (12%) with or without MTPJ pinning (80%). Mean follow up was 53 weeks (range 5-170). Patients were screened for associated risk factors, including diabetes mellitus (8%), tobacco use (5%), neuropathy (1%), and additional concurrent procedures (96%). Complications were defined as superficial or deep infection, painful scars, and reoperation. Analysis was conducted using the Wilcoxon-Mann-Whitney test or Fisher's exact tests for continuous and categorical variables, respectively. Risk factors were analyzed using univariate logistic analysis to produce odds ratios (OR) with a 95% confidence interval (CI) and an inclusion criterion of a P-value, P > .2 for multivariate analysis as determined by Wald tests (significance at P < .05 for final modeling). RESULTS: Overall, there were 31 total complications (15%) demonstrated by 14 superficial infections (6.8%) and 17 painful scars (8.3%) along with three reoperations (1.4%). All reoperations were performed for deformity or instability, not scar revision. There were no deep infections. No increased odds of complications were found with suture anchor repair, MTPJ pinning, neuropathy, or diabetes. Patients that used tobacco had 7.5 (CI 1.66, 34.06) the odds of developing any wound complication compared with nonsmokers. Tobacco use was also found to significantly increase the odds of superficial infection by 9.8 (CI 2.08, 46.15). There was no increase in painful scars or reoperation in tobacco users. This study did not find an increased complication rate with additional ipsilateral procedures performed at the time of surgery. CONCLUSION: To our knowledge, this is the largest study evaluating the direct plantar approach to PPR as well as the evaluation of associated complications with the plantar incision. With low complication and minimal reoperation rates, the results of this study have demonstrated the clinical viability of plantar-based incisions. Previous studies have demonstrated the success of PPR and correction of deformity with a direct approach. This case series further demonstrates the safety and efficacy of plantar-based incisions, particularly for direct PPRs. LEVEL OF EVIDENCE: IV Retrospective Case Series. CATEGORY: Lesser Toes.

High Utility of the 1st Metatarsal Phalangeal Joint Fusion.

Fusion of the first metatarsophalangeal joint has been used by foot and ankle surgeons as a reproducible and useful means of treating end-stage arthritis of the great toe. However, the overall utility and successful outcomes of this procedure have led to its incorporation into the treatment of more significant bunion deformities, reconstruction forefoot, and salvage procedures. The authors review surgical fixation methods, offer insightful technical pearls for challenging cases and share examples of complex reconstructive and salvage procedures.

Deformity Correction of the Midfoot/Hindfoot/Ankle.

The correction of the deformed arthritic foot and ankle is a complicated and somewhat controversial topic. After conservative methods fail, there is a wide range of possible bony procedures and arthrodesis that maybe performed. The appropriate work up and understanding of the pathomechanics is vital to the correct choice of procedures to correct these deformities. Once the work up and procedure selection is done, the operation must also be technically performed well and with efficiency, as most often the condition is corrected with a variety of procedures. This article discusses some of the most common procedures necessary to fully correct deformity of the midfoot, hindfoot, and ankle. This article will also discuss the authors' technique and pearls.

The Role of Secondary Imaging Techniques for Assessing Bone Mineral Density in Elderly Ankle Fractures.

Elderly ankle fractures in the elderly represent a substantial healthcare burden. Dual-energy x-ray absorptiometry (DXA) is the gold standard for diagnosis of osteoporosis. However, there is emerging research regarding secondary imaging techniques to evaluate bone mineral density (BMD). The purpose of this systematic review was to summarize the role of secondary imaging techniques for measuring BMD in elderly ankle fractures. A literature search was undertaken using relevant search terms. Articles were screened for suitability and data extracted where studies met inclusion criteria and were of sufficient quality. Eight studies were included in the systematic review. Computed tomography (CT) may have a role in preoperative surgical planning, provide an explanation for injury patterns in elderly patients, and may be correlated with clinical outcomes. High-resolution peripheral quantitative CT may be better suited than DXA for the assessment of ankle fractures due to the resolution of the image and its ability to distinguish between bone compartments, as well as provide a more accurate estimation of bone quality. Quantitative ultrasound has shown promise as a tool for measuring BMD in patients with osteoporosis, but is not able to detect osteoporosis in patients with ankle fractures. This paper helps define the role of each modality in the spectrum of care in the evaluation of osteoporosis as it pertains to elderly ankle fractures.

Research Activity Among Foot and Ankle Surgery Fellows: A Systematic Review.

Surgical residents cite a number of reasons to pursue a fellowship training program including improving surgical skills, furthering medical research, pursuing an academic practice, or to generally become an overall better trained surgeon and clinician. The interest in foot and ankle surgery fellowships has increased among graduating residents as have the number of fellowship programs. Since the introduction of these programs, there has been no formal investigation of the scholarly activity among foot and ankle surgery fellows. Using PubMed, a systematic review was conducted from papers published by fellows participating in American College of Foot and Ankle Surgeons or American Podiatric Medical Association approved fellowships during 2013 to 2019. A total of 76 of the 128 identified fellows published research during or within one year of completing their fellowship. Fellows that published at least once prior to fellowship were more likely to publish during fellowship compared to those who had no publication history. Over this 6-year period, fellows contributed to 279 manuscripts where they maintained primary authorship of 34.41% of the publications, across 35 journals, with the most common being the Journal of Foot and Ankle Surgery. Results of this study provide a survey of the scholastic activity among foot and ankle surgery fellows and could be used by applicants and evaluators to stratify applicant aptitude. These results could also serve as a scholarly activity benchmark for current fellows and a method of gauging scholarly involvement for new and current fellowships.

Bone Mineral Density Testing in Patients Undergoing Total Ankle Arthroplasty: Should We Pay More Attention to the Bone Quality?

Total ankle arthroplasty (TAA) has become one of the standard treatments for end-stage ankle arthritis. Long-term TAA survivorship is reported from 63% to 95%, with aseptic loosening being the most common mode of failure. Several studies have shown that low bone mineral density (BMD) of the hip affects the longevity of prosthetic implants. The role of Dual energy X-ray absorptiometry for TAA has not been established. The purpose of this review was to define the role of BMD in TAA outcomes and the role of Dual energy X-ray absorptiometry in measuring periprosthetic BMD. There is a paucity of information and published literature regarding the relationship between BMD and TAA. From attempting this systematic review, we hope to highlight that much of the focus in total ankle arthroplasty has emphasized implants and relatively little has focused on the quality of bone into which the prostheses are implanted.

Outcomes and Incidence of Complications Following Endoscopic Gastrocnemius Recession: A Systematic Review.

Introduction: Equinus contracture of the ankle can lead to a multitude of foot and ankle pathologies. The gastrocnemius recession has been used to address equinus deformity via various methods, including either an open or an endoscopic approach. Open techniques require increased intraoperative time and complication risks of sural nerve injury, wound complications, and poor cosmesis. Resultantly, the aim of the current study is to review the complications and outcomes of the endoscopic gastrocnemius recession. Methods: A systematic review of electronic databases was performed. The authors compiled data from retrospective and prospective patient studies including general patient demographics, outcomes, qualitative scoring measures, complications, and surgical technique. Results: Eleven studies met our inclusion criteria. A total of 697 feet in 627 patients were included in the current systematic review. The weighted mean age was 45.3 years and weighted mean follow-up was 18.4 months. The most common indication for an endoscopic gastrocnemius recession was equinus contracture. The weighted mean preoperative ankle range of motion was -2.3° and the weighted postoperative ankle range of motion was 10.9°. The most common complications included plantarflexion weakness of the ankle at 3.5%, a sural nerve injury of 3.0% and wound complication rate was 1.0% with no deep infection. The overall complication rate was 7.5%. Conclusion: The endoscopic gastrocnemius recession is a valuable surgical tool in the treatment of ankle equinus. The endoscopic approach has satisfactory outcomes including low incidence of plantarflexion weakness and sural neuritis. Patients should be counseled on these risks preoperatively. Compared with previously reported systematic review of the open technique, the endoscopic approach has a lower overall incidence of complications. Prospective clinical trials comparing open and endoscopic techniques are warranted.Levels of Evidence: Level IV.

Anterior Ankle Incision Wound Complications Between Total Ankle Replacement and Ankle Arthrodesis: A Matched Cohort Study.

The anterior incision is commonly used for total ankle replacement (TAR) and ankle arthrodesis. Historically, the anterior incision has demonstrated a high incidence of complications. The purpose of this study was to evaluate anterior incisional healing and soft tissue complications between TAR and ankle arthrodesis with anterior plate fixation.This was an IRB-approved retrospective review of wound healing and other complications among 304 patients who underwent primary TAR (191 patients) or ankle arthrodesis (113 patients) via the anterior approach over a 4-year period. The operative approach, intraoperative soft tissue handling, and postoperative protocol for the first 30 days were the same between groups. The mean follow-up was 11.8 months. To diminish the effect of selection bias, a subgroup analysis was performed comparing 91 TAR patients matched to an equal number of demographically similar ankle arthrodesis patients. Overall, 19.7% of patients experienced delayed wound healing greater than 30 days. Although the TAR and arthrodesis subgroups had dissimilar demographics, there was no difference in outcomes. Between matched pairs, no statistically significant differences were observed; however, trends were identified with matched cohort groups when compared to the overall patient series. These trends toward statistically significant differences in delayed wound healing and incidence of wound care in the matched cohort groups warrants further investigation in larger series or multicenter study. Further work is needed to identify the modifiable risk factors associated with the anterior ankle incision.

Safety Profile Associated With Calcaneal Autograft Harvesting Using a Reaming Graft Harvester.

BACKGROUND: Foot and ankle surgery often requires bone healing, whether in elective arthrodesis or trauma. While primary bone healing is possible, the rate of nonunion in foot and ankle surgery remains variable. The addition of autogenous bone graft can allow for higher union rates by adding to the biology at the site of bone healing. Harvesting autogenous bone graft from the calcaneus for foot and ankle surgery can be done quickly and efficiently and allow for an adequate amount of graft. METHODS: A retrospective chart and radiographic review was performed for 1438 patients at a single center between August 1, 2015, and December 15, 2018, who underwent calcaneal autograft harvesting using a power-driven reaming graft harvester. RESULTS: In total, 966 patients were included and evaluated for the safety and complication rate associated with the procedure. Only 1 patient (0.1%) had a major complication, and there were 14 minor complications (1.4%). CONCLUSION: The safety profile and low complication rate of this case series demonstrate that this simple and efficient calcaneal autograft harvest technique can be considered when a small to moderate amount of autogenous bone graft is required to augment bone healing. LEVEL OF EVIDENCE: Therapeutic level IV, case series.

Association Between Bone Mineral Density and Elderly Ankle Fractures: A Systematic Review and Meta-Analysis.

Ankle fractures are becoming increasingly more common in the elderly population and present a significant burden to the United States health care system. Many factors have been associated with fragility ankle fractures including age, gender, body mass index, diabetes, tobacco use, and osteoporosis. However, the literature is inconsistent regarding the relationship between ankle fractures and osteoporosis. The primary aim of this meta-analysis was to quantify the relationship between bone mineral density (BMD) in elderly patients with ankle fractures compared with BMD in elderly patients without ankle fractures. A literature search was undertaken using relevant search terms. Articles were screened for suitability and data extracted where studies met inclusion criteria and were of sufficient quality. Data were combined using standard meta-analysis methods. Seven studies were used in the final analysis. A small-pooled effect size was found indicating the control group had increased BMD regardless of measurement used (95% confidence interval 0.09-0.58; I2 = 98.39%). Lower femoral neck BMD showed a small-pooled effect size (femoral neck 0.36; 95% confidence interval 0.00-0.73; I2 = 94.91%) with the ankle fracture cohort. This is the first meta-analysis to quantify the relationship between BMD and ankle fractures in the elderly population. Elderly ankle fractures showed a significant association with femoral neck BMD. The current data can be used in orthopedic clinics and Fracture Liaison Service programs to assign the appropriate subgroup of ankle fracture patients to investigative and treatment groups, assess fracture risk, and serve as an indication for secondary fracture prevention by stimulating an osteoporosis prevention workup. There may be a role for a team approach to fracture care including metabolic optimization.

The Incidence of Nonunion of the Naviculocuneiform Joint Arthrodesis:A Systematic Review.

Naviculocuneiform (NC) joint arthrodesis is an effective procedure to treat pain and provide stability to the medial column. Various forms of fixation have been described for NC arthrodesis. Despite this, the available literature is scant and questions remain regarding nonunion rate and contributory factors. A systematic review of the literature was undertaken to determine the rate of nonunion for NC joint arthrodesis. Seven studies involving 139 NC joint arthrodeses met inclusion criteria. The nonunion rate was 6.5% at a weighted mean follow-up of 73.2 months. There is insufficient evidence to provide a practice guideline based on the current literature. Adequately powered prospective clinical trials comparing well-matched patient groups with long-term follow-up are required to limit systematic error and enhance external validity. Specific outcomes measures should include union, functional assessment, complications, and cost-benefit analysis.

Incidence of Nonunion of the Hallux Interphalangeal Joint Arthrodesis: A Systematic Review.

Hallux interphalangeal joint arthrodesis is an effective procedure to treat pain and provide stability and is often performed for intrinsic pain to the hallux interphalangeal joint. Additionally, this procedure is typically used in concert with the Jones tenosuspension. Although this as an accepted technique, the available data are scant, and questions remain regarding nonunion rates and contributory factors to poor healing. A systematic review of the reported data were undertaken to determine the rate of nonunion for hallux interphalangeal joint arthrodesis. Seven studies involving 313 hallux interphalangeal joint arthrodeses met the inclusion criteria. The nonunion rate was 28.3% at a weighted mean follow-up period of 8.4 months. The overall complication rate was 33.0%. Considering the increased rate of complications and nonunion rate for this commonly used procedure, additional prospective comparative analyses are needed regarding this topic to identify important patient demographic data and determine superior fixation constructs.

Medial Structure Injury During Suture Button Insertion Using the Center-Center Technique for Syndesmotic Stabilization.

BACKGROUND: The center-center technique for syndesmosis fixation has been described as an improved and reliable technique for proper reduction of the syndesmosis during ankle fracture repair. Concurrently, the use of flexible fixation with a suture button is becoming an established means of syndesmosis stabilization. The purpose of this cadaveric study was to assess for medial structure injury during the placement of a suture button using the center-center technique for ankle syndesmosis repair at 3 insertion intervals. METHODS: Simulated open syndesmosis repair was performed on 10 cadaveric specimens. Three intervals were measured at 10 mm, 20 mm, and 30 mm proximal to the level of the distal tibial articular surface along the fibula. Proper longitudinal alignment of the center-center technique was completed under fluoroscopic guidance and was marked on the medial aspect of the tibia. The 3 intervals were drilled in the appropriate technique trajectory. The suture button was subsequently passed through each drill-hole interval. A single observer used a digital caliper to measure the distance from each suture button aperture with respect to the tibialis anterior tendon, tibialis posterior tendon, and greater saphenous vein and nerve. RESULTS: A total of 30 interval measurements (10 cadavers with 3 suture button segments each) were used for data analysis. Direct impingement on the greater saphenous vein was seen in 11 of 30 (36.6%) interval measurements. Six of the 11 (54.5%) observed saphenous structure impingement events occurred at the 10-mm drill hole. CONCLUSION: The results of the present study suggest that the use of the center-center technique for syndesmosis repair with suture button fixation risks preventable injury to the greater saphenous neurovasculature. CLINICAL RELEVANCE: To understand the medial ankle anatomy, as it pertains to insertion of flexible syndesmotic fixation in a cadaveric model, to aid in prevention of clinical iatrogenic injury.

Cross-Sectional Analysis of the Distal Fibular Intramedullary Canal: A Cadaveric Evaluation.

Fractures of the distal fibula secondary to rotational ankle injuries are one of the most common injuries requiring surgical intervention. The aim of this study was to describe the anatomy of the distal fibular medullary canal as a means of aiding in surgical management with an intramedullary device. Twenty fresh cadaveric below-knee specimens (group 1, 10 in 2015, group 2, 10 in 2016) were dissected to expose the distal fibular. Fifteen (10 mm each) segments were sectioned with a sagittal saw from the distal tip proximally and measured with a digital caliper. In group I, the widest and narrowest fibular diameter was at the 20-mm interval (mean 15.02 mm) and 90-mm interval (mean 3.51 mm), respectively. From 70 to 120 mm, the mean diameter was less than 4.0 mm. In group 2, the widest and narrowest diameter was at the 20-mm interval (mean 15.05 mm) and 100-mm interval (mean 4.33 mm), respectively. From 70 to 140 mm, the mean diameter was less than 5.0 mm. The combined mean diameter at the 60- to 80-mm intervals were 4.99 ± 1.70, 4.35 ± 1.63, and 4.02 ± 1.35 mm, respectively. Based on our investigation, we propose an intramedullary device diameter of 4.5 to 5.0 mm in diameter with a length of 60 to 80 mm may provide most appropriate bony purchase to achieve acceptable cortical contact for expected osseous compression. LEVELS OF EVIDENCE: Level IV: Cadaveric case series.