Midfoot Fusion Using Superconstructs for the Charcot Foot: Current Techniques and Complications.

Neuroarthropathy of the foot and ankle presents a series of challenges. The treating physician faces a perfect storm of pathomechanics, deformity, and medical comorbidities. Successful treatment requires a systematic approach in diagnosis, nonsurgical management, surgical management, and long-term maintenance of the affected extremity. Nonsurgical care of the Charcot foot remains the mainstay of treatment and is successful in most cases. Surgery has become more accepted for patients with severe deformity. The concept of a superconstruct has been introduced to describe modern surgical techniques and implants that have been developed since the early 2000s where stability and durability are maximized. A superconstruct is defined by four factors: (1) fusion is extended beyond the zone of injury to bridge the area of bony dissolution; (2) aggressive bone resection is performed to allow for adequate reduction of deformity without undue tension on the soft-tissue envelope; (3) stronger implants are used than for nonneuropathic fusion procedures, including some specifically developed for fixation of the Charcot foot; and (4) the devices are applied in a position that maximizes mechanical stability to allow the implants to become load sharing. It is important to review the current techniques and implants used in fusion of the neuropathic midfoot and discuss the expected outcomes and complications based on the authors' experience.

Pantalar arthrodesis for post-traumatic arthritis and diabetic neuroarthropathy of the ankle and hindfoot.

BACKGROUND: Pantalar arthrodesis is an important salvage option for stabilizing the hindfoot and salvaging the limb following trauma or collapse. This report evaluates the healing rates and complications which occur in diabetics and post-traumatic patients. MATERIALS AND METHODS: Twenty patients presenting with post-traumatic arthritis of the ankle-hindfoot (twelve) or with Type II or Type IIIA Charcot arthropathy (eight) were managed with a pantalar fusion. Followup averaged 46 months. Patients were evaluated using the Short Form-36 (SF-36), the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score, the Short Musculoskeletal Function Assessment (SMFA) and the Visual Analog Pain Scale (VAS). RESULTS: There were no amputations in either group. Casting averaged 14.9 weeks, full weightbearing was achieved at 25.1 weeks and time to union averaged 44.1 weeks. Average age was 56.3 yrs. and BMI averaged 34.2. Fourteen patients (70%) had their surgery performed in multiple stages. Acceptable outcomes were noted for all patients for the SF-36, AOFAS and SMFA scores. VAS scores averaged 2.2. There were ten complications (50%); four patients (two in each group) required additional surgery. CONCLUSIONS: Pantalar arthrodesis is a reasonable salvage option for patients with severe post traumatic arthropathy and neuropathic arthropathy. Patients should be informed of the increased risks as well as the long periods of postoperative immobilization and nonweightbearing. We believe a pantalar arthrodesis can produce acceptable outcomes regardless of the cause of disability, with a staged or single approach, and whether the surgery is performed with plates and screws or an intramedullary device.

Midtarsal arthrodesis in the treatment of Charcot midfoot arthropathy. Surgical technique.

BACKGROUND: Fracture-dislocation of the midfoot with collapse of the longitudinal arch is common in patients with neuropathic arthropathy of the foot. In this study, we describe a technique of midfoot arthrodesis with use of intramedullary axial screw fixation and review the results and complications following use of this technique. METHODS: A retrospective study of twenty-two patients who had undergone surgical reconstruction and arthrodesis to treat Charcot midfoot deformity was performed. Bone resection and/or osteotomy were required to reduce deformity. Axially placed intramedullary screws, inserted either antegrade or retrograde across the arthrodesis sites, were used to restore the longitudinal arch. Radiographic measurements were recorded preoperatively, immediately postoperatively, and at the time of the last follow-up and were analyzed in order to assess the amount and maintenance of correction. RESULTS: Patients were evaluated clinically and radiographically at an average of fifty-two months. Complete osseous union was achieved in sixteen of the twenty-two patients, at an average of 5.8 months. There were five partial unions in which a single joint did not unite in an otherwise stable foot. There was one nonunion, with recurrence of deformity. All patients returned to an independent functional ambulatory status within 9.5 months. Weight-bearing radiographs showed the talar-first metatarsal angle, the talar declination angle, and the calcaneal-fifth metatarsal angle to have improved significantly and to have been corrected to nearly normal values by the surgery. All measurements remained significantly improved, as compared with the preoperative values, at the time of final follow-up. There were no recurrent dislocations. Three patients had a recurrent plantar ulcer at the metatarsophalangeal joint that required additional surgery. There were eight cases of hardware failure. CONCLUSIONS: Open reduction and arthrodesis with use of multiple axially placed intramedullary screws for the surgical correction of neuropathic midfoot collapse provides a reliable stable construct to achieve and maintain correction of the deformity.

Lasso stitch with peroneal retinaculoplasty for repair of fractured os peroneum: a report of two cases.

UNLABELLED: Fracture of the os peroneus with retraction of the peroneus longus tendon can lead to weakness, instability, and progressive foot deformity. Treatment recommendations vary and include simple immobilization, repair of the fractured ossicle, excision of part or all of the fractured ossicle with repair of the tendon and tenodesis with the peroneus brevis tendon. We present two patients treated with excision of the proximal fragment and repair of the tendon to the distal fragment with relief of pain and restoration of function. The distal fragment was captured with a looped suture which allowed avoidance of a plantar exposure while still achieving an adequate repair. We also describe a technique for retinaculoplasty of the inferior peroneal retinaculum which we believe important to prevent postoperative adhesions to the tendon. LEVEL OF EVIDENCE: Level V, expert opinion. See Guidelines for Authors for a complete description of levels of evidence.

Surgical repair of acute and chronic tibialis anterior tendon ruptures.

BACKGROUND: Rupture of the tibialis anterior tendon is an uncommon disorder that can cause a substantial functional deficit as a result of loss of ankle dorsiflexion strength. We are not aware of any reports on a large clinical series of patients undergoing surgical repair of this injury. METHODS: Nineteen tibialis anterior tendon ruptures were surgically repaired in eighteen patients ranging in age from twenty-one to seventy-eight years. Early repair was performed for one traumatic and seven atraumatic ruptures three days to six weeks after the injury. Delayed reconstruction was performed for two traumatic and nine atraumatic ruptures that had been present for seven weeks to five years. Direct tendon repair was possible for four of the early repairs and three of the delayed reconstructions. An interpositional autogenous tendon graft was used for four early repairs and eight delayed reconstructions. Patients were reassessed clinically and with the American Orthopaedic Foot and Ankle Society hindfoot score at an average of 53.3 months after surgery. RESULTS: The average hindfoot score improved significantly from 55.5 points preoperatively to 93.6 points postoperatively. The surgical results did not appear to vary according to patient age, sex, or medical comorbidity. Complications requiring a second surgical procedure occurred in three patients. Recovery of functional dorsiflexion and improvement in gait was noted in eighteen of the nineteen cases. Ankle dorsiflexion strength was graded clinically as 5/5 in fifteen of the nineteen cases. Three patients regained 4/5 ankle dorsiflexion strength, and one patient had 3/5 strength with a poor clinical result. CONCLUSIONS: Surgical restoration of the function of the tibialis anterior muscle can be beneficial regardless of age, sex, medical comorbidity, or delay in diagnosis. Early surgical treatment may be less complicated than delayed treatment, and an intercalated free tendon graft and/or gastrocnemius recession may be necessary to achieve an appropriately tensioned and balanced repair.

Midtarsal arthrodesis in the treatment of Charcot midfoot arthropathy.

BACKGROUND: Fracture-dislocation of the midfoot with collapse of the longitudinal arch is common in patients with neuropathic arthropathy of the foot. In this study, we describe a technique of midfoot arthrodesis with use of intramedullary axial screw fixation and review the results and complications following use of this technique. METHODS: A retrospective study of twenty-two patients who had undergone surgical reconstruction and arthrodesis to treat Charcot midfoot deformity was performed. Bone resection and/or osteotomy were required to reduce deformity. Axially placed intramedullary screws, inserted either antegrade or retrograde across the arthrodesis sites, were used to restore the longitudinal arch. Radiographic measurements were recorded preoperatively, immediately postoperatively, and at the time of the last follow-up and were analyzed in order to assess the amount and maintenance of correction. RESULTS: Patients were evaluated clinically and radiographically at an average of fifty-two months. Complete osseous union was achieved in sixteen of the twenty-two patients, at an average of 5.8 months. There were five partial unions in which a single joint did not unite in an otherwise stable foot. There was one nonunion, with recurrence of deformity. All patients returned to an independent functional ambulatory status within 9.5 months. Weight-bearing radiographs showed the talar-first metatarsal angle, the talar declination angle, and the calcaneal-fifth metatarsal angle to have improved significantly and to have been corrected to nearly normal values by the surgery. All measurements remained significantly improved, as compared with the preoperative values, at the time of final follow-up. There were no recurrent dislocations. Three patients had a recurrent plantar ulcer at the metatarsophalangeal joint that required additional surgery. There were eight cases of hardware failure. CONCLUSIONS: Open reduction and arthrodesis with use of multiple axially placed intramedullary screws for the surgical correction of neuropathic midfoot collapse provides a reliable stable construct to achieve and maintain correction of the deformity.

Arthrodesis of the subtalar and talonavicular joints for correction of symptomatic hindfoot malalignment.

BACKGROUND: Triple arthrodesis has long been used for the treatment of painful malalignment or arthritis of the hindfoot. However, the effect of fusion on adjacent joints has sparked interest in a more limited arthrodesis in patients without involvement of the calcaneocuboid joint. METHOD: Results of 16 feet in 14 patients who had a modified double arthrodesis for symptomatic flatfoot, cavovarus deformity, or hindfoot arthritis were reviewed retrospectively with a minimum followup of 18 (range 18 to 93) months. The most common diagnosis contributing to the hindfoot deformity was pes planovalgus. All operations were done with a consistent technique using rigid internal fixation with screws. In 15 feet, a concomitant gastrocnemius recession for equinus contracture was done at the time of the primary surgery. Clinical evaluation was based on the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale in addition to subjective assessments of pain, function, shoewear, cosmesis, and overall satisfaction. Radiographic evaluation included measurements of the anterior-posterior talo-second metatarsal angle, lateral talocalcaneal angle, and lateral talo-first metatarsal angle, and notation of arthritic changes of the ankle, calcaneocuboid, and midfoot joints, as well as an assessment of time to union of all arthrodeses. RESULTS: The average AOFAS Ankle-Hindfoot Scale improved from 44.7 preoperatively to 77.0 postoperatively (p < 0.01). Subjectively, patients experienced improvements in pain, function, cosmesis, and shoewear. Overall, all patients were satisfied and would have the procedure again under similar circumstances. Radiographically, all parameters statistically improved. There was an increase in arthritic scores for six ankle, six calcaneocuboid, and five midfoot joints. One talonavicular joint nonunion occurred in a rheumatoid patient, requiring revision arthrodesis. CONCLUSIONS: We have concluded that simultaneous arthrodesis of the talonavicular and subtalar joints is a reasonable treatment in the subset of patients with symptomatic hindfoot malalignment whose calcaneocuboid joints are not involved in the primary disease.

Surgical treatment of the hallux rigidus.

Numerous surgical procedures are available for the treatment of hallux rigidus. The choice of a particular one depends on the severity of the disease, patient activity level, and expectations about the surgery. Cheilectomy is recommended for early disease and may be associated with an osteotomy of the proximal phalanx. For active patients who have severe hallux rigidus, arthrodesis and biologic interposition arthroplasties have shown good results. Keller arthroplasty is reserved for low demand patients; prosthetic replacements are not recommended at this time.

Outcome of surgical treatment of tarsal tunnel syndrome.

One hundred and eight ankles in 72 patients were evaluated from July 1986 to July 1997 with clinical findings and positive electrodiagnostic studies of tarsal tunnel syndrome. Clinical data included physical findings, subjective complaints, duration of symptoms, trauma history, steroid injections, nonsteroidal use and workman's compensation involvement. Associated medical conditions included diabetes, back pain and arthritis. Sixty-two patients underwent tarsal tunnel release, with 13 of them bilateral. There were 44 females and 18 males, 35 right feet and 40 left feet. The average age was 49 years. Preoperative symptom duration was 31 months. Average length of follow-up was 58 months. Average time for return to usual activity was nine months. All patients had at least a 12-month follow-up, and compared with both (Maryland Foot Score) MFS and AOFAS postoperative scores. Preoperative MFS scores obtained prior to 1994, were 61/100 (average), and postoperative MFS scores were 80/100 (average). Postoperative AOFAS scores were 80/100 (average). Patients with symptoms less than one year had postoperative MFS/AOFAS scores significantly higher than those with symptoms greater than one year. The most common surgical findings included arterial vascular leashes indenting the nerve and scarring about the nerve. Varicosities and space occupying lesions were present also. The outcome of surgery was not affected by the presence or absence of trauma. Patients with tarsal tunnel syndrome warrant surgery when significant symptoms do not respond to conservative management. Meticulous surgical technique must be followed. Improvement in foot scores is predictable even when a discrete space-occupying lesion is not present and when symptoms have been present for periods of greater than one year.

Treatment of talar osteochondral lesions using local osteochondral graft.

Twelve patients with an osteochondral lesion of the talus were treated with excision of the lesions and local osteochondral autogenous grafting. The lesion was accessed through a replaceable bone block removed from the anterior tibial plafond. The graft was harvested from the medial or lateral talar articular facet on the same side of the lesion. The average age of the patients was 41 years and duration of symptoms was 90 months (ave.). There were six males and six females with the right talus involved in eight and the left in four patients. Graft sizes ranged from four to eight millimeters in diameter. There was a significant improvement in the AOFAS score from 64.4 (ave.) pre-operatively to 90.8 (ave.) postoperatively (p<0.0001), at a follow-up of 25.3 months (ave.). The AOFAS score was slightly higher in patients under 40 years of age and in those without pre-existing joint arthritis. All patients were very satisfied with the procedure. Arthroscopy performed in two patients at six and 12 months following surgery showed good graft incorporation. No complications occurred at the donor site or the site of bone block removal on the distal tibia. The results show that stage III and IV talar osteochondral lesions can be accessed successfully excising a tibial bone block and using local autogenous osteochondral graft harvested from the ipsilateral talar articular facet.

Persistent Foot and Ankle Pain in Young Athletes.

In brief When young athletes experience brief Persistent foot or ankle pain, the differential diagnosis includes overuse syndromes, exacerbated chronic or congenital conditions, and poor healing of earlier acute injuries. Often, prompt diagnosis and treatment of an acute injury might have prevented a chronic condition. Conditions discussed in this article include distal fibular epiphyseal fracture, lateral ligament sprain, tibiofibular ligament sprain, peroneal tendon dislocation, Achilles tendinitis, Se- ver's disease, talar dome osteochondral fracture, and tarsal coalition.

Tarsometatarsal Joint Injury.

In brief Injuries of the tarsometatarsal joint complex, though not common in athletes, can cause prolonged disability. The severity of these injuries often is not recognized, since subtle subluxations are difficult to diagnose. Certain radiographic signs help make the diagnosis; fluoroscopy with anesthesia may be necessary to determine the stability of the joint. Casting is sufficient for patients who have stable injuries, but those who have an unstable joint require open reduction and internal fixation.

Managing Toenail Trauma.

In brief Acute subungual hematoma or seroma of an active patient's toenail results from direct trauma or repetitive shear force to the nail apparatus. Though painful, the condition is usually benign. Accurate diagnosis of underlying nail bed injury or distal phalanx abnormality is needed for appropriate treatment and to prevent nail plate deformity. Evacuating the fluid quickly alleviates pain, allowing athletes to resume their activities.

Feet Under Force.

In brief Foot sprains and strains are as varied as the sports that produce them, and these injuries affect athletes at all competitive levels- even the weekend warrior. An understanding of how the foot's structures respond to trauma and of how to best elicit information through the physical exam can help a physician pinpoint the injury And determining injury severity can help focus the level of treatment needed for a sure-footed return to activity.