First Tarsometatarsal Joint Fusion for Hallux Valgus Deformity: A Retrospective Comparison of Two Fixation Constructs Regarding Initial Maintenance of Correction and Complications: Traditional Crossing Screw Fixation Versus Dorsomedial Locking Plate and Intercuneiform Compression Screw.

Various fixation constructs exist to address hallux valgus when performing a first tarsometatarsal joint arthrodesis. The goal of this present study is to compare complication rates, and degree and maintenance of angular correction between a dorsomedial locking plate with intercuneiform compression screw construct versus traditional crossing solid screw fixation construct. The plate plus intercuneiform compression screw construct fixation utilized a combined sagittal saw and curette method of joint preparation while the crossed screw fixation group utilized a curette and bur technique. A retrospective review was conducted of consecutive patients who underwent a midfoot fusion using either constructs. Sixty four total feet in 56 patients were enrolled in the study. Twenty four consecutive patients (32 feet) who underwent a midfoot arthrodesis using the locking plate and intercuneiform fixation were fully fused (100%) by 10 weeks postoperatively, with no incidents of nonunion and one deep vein thrombosis event. Thirty two consecutive patients (32 feet) who underwent midfoot arthrodesis with crossing screw fixation had 2 nonunion events, one that was asymptomatic and the other that required a revision midfoot fusion. There was a statistically significant improvement from the pre-operative intermetatarsal angle, hallux abductus angle compared to the 10 week and 1 year radiographs (p < .05) for the entire cohort for both fixation constructs. There was a statistically significant increase in American College of Foot and Ankle Surgery first ray scores from pre-op to 1 year follow-up for both fixation constructs. Overall, the dorsomedial locking plate plus intercuneiform compression screw fixation construct better maintains Intermetatarsal angle (IMA) correction at midterm follow-up compared to the traditional crossing screw construct. Both cohorts overall demonstrate similar fusion rates at 10 weeks, nonunion events, incidences of broken hardware, hardware removal, deep vein thrombosis, neuritis at 1 year postoperatively, and hallux varus.

A Novel Manipulation Technique for Lapidus Fusion in Correction of Hallux Valgus Deformity With Underlying Metatarsus Adductus: A Case Series.

Underlying metatarsus adductus (MA) is commonly seen in patients with hallux valgus (HV) deformity, with implications regarding procedure selection and hallux valgus recurrence. Lapidus, or first tarsometatarsal fusion, is commonly performed allowing reduction in intermetatarsal angle (IMA) but this procedure has not been established as an approach to provide partial correction of MA deformity. Retrospective assessment of preoperative and postoperative metatarsus adductus angle (MAA), IMA and hallux abductus angle (HAA) in patients treated with Lapidus fusion for HV. Significance was determined via paired t test with a p value of <.05. All cases involved manual transverse plane manipulation to reduce both IMA and MAA during screw insertion. Intermetatarsal angle and Engel's angle were measured on preoperative AP radiographs to determine the presence of underlying MA in patients undergoing Lapidus fusion for HV. Ten weeks and 1 year postoperative radiographs were measured to determine degree of correction of IMA, HAA, and MAA. Thirty-four patients met inclusion criteria, which is approximately 46% of our sample population. The average preoperative IMA was 19.4˚ (range 12-32) and the average postoperative IMA was 9.7˚ (range 6-14). The average preoperative Engel's angle was 27.4˚ (range 24-34) and the average postoperative Engel's angle was 22.6˚ (range 15-28) with mean improvement in MA of 6.6˚. Of the 34, 27 (79.4%) patients had a normal Engel's angle at 10 weeks postoperatively. All measures of change met level of significance (p < .05). Of the 34 patients, 21 had radiographs taken beyond the 1 year mark (average 53 weeks). These patients were found to have an average Engel's angle of 23.0˚, which is not statistically significantly different from their 10 week measurements. Of the 21 patients, 17 (81%) maintained normal Engel's angle past 1 year. Metatarsus adductus varies regarding degree of reducibility and complicates preoperative angular measurement and correction of HV. Based on these findings, we recommend Lapidus fusion using this specified manipulation technique to obtain comprehensive transverse plane correction.

A Review of Consecutive Cases to Identify the Rate of Underlying Osteomyelitis in Patients Undergoing Surgical Treatment of Gangrene of the Forefoot and Impact of Acute Infection on Outcome Following Amputation.

Medical literature offers no clear treatment guidelines when performing amputations for gangrene of the forefoot despite a high percentage that suffer poor outcome due to infection. Gas gangrene and wet gangrene are often preceded by dry stable gangrene. This is a retrospective review of consecutive patients who underwent forefoot amputation and bone biopsy as treatment of forefoot gangrene by a single surgeon. Procedures performed included digital, ray, or transmetatarsal amputation with bone biopsy sent for both culture and histopathologic evaluation. One hundred patients (35 females, 65 males) met inclusion criteria. Mean follow-up was 9.6 months. Mean age was 63.5 years old. Forty-six out of 100 (46%) had elective amputation while 54/100 (54%) were emergent for acute infection. Vascular intervention was performed in 52/100 (52%). Seventy-eight out of 100 (78%) had histopathologic diagnosis of acute osteomyelitis while 82/100 (82%) had positive bone culture. Patients with acute infection had worse outcomes, with higher rates of more proximal amputation and delayed wound healing. We found that 79.7% of patients who underwent forefoot amputation due to gangrene had underlying osteomyelitis. We also found that those with acute infection during the time of amputation had poorer postamputation outcomes such as delayed wound healing, revision surgery, and high rates of more proximal amputation. Therefore, it may imply that earlier amputation of stable gangrene prior to becoming acutely infected may decrease the occurrence of osteomyelitis and avoid some of the preventable postamputation complications. Further studies are warranted.

Accuracy of Palpation to Identify the Medial Branch of the Medial Dorsal Cutaneous Nerve in Medial Column Surgery: Correlation of Preoperative Nerve Marking With Intraoperative Findings During Lapidus Fusion.

The medial branch of the medial dorsal cutaneous nerve is frequently encountered in medial column surgery. Postoperative sensory nerve symptoms can lead to dissatisfaction and suboptimal outcome. The purpose of this case series is to correlate intraoperative nerve location on direct viewing with preoperative nerve localization to assess the accuracy of a specific nerve palpation technique. Hundred consecutive patients undergoing elective Lapidus fusion were prospectively evaluated. Preoperative nerve localization and intraoperative comparison was performed along with assessment of nerve position in relation to the cuneiform and first tarsometatarsal joint. Preoperative nerve identification correlated with intraoperative findings in 99 of 100 consecutive cases. In 1 of 100 cases, the palpated nerve was proximal to the zone of dissection and was not visualized. The medial branch of the medial dorsal cutaneous nerve crossed the dorsal Lapidus incision at the medial cuneiform or first metatarsal base level in 95 of 100 cases; at the mid metatarsal level in 2 of 100 cases; and proximal to the medial cuneiform in 3 of 100 cases.

Ideal Angle of Upper and Lower Syndesmotic Fixation Based on Weightbearing Computed Tomographic Imaging in Uninjured Ankles.

Syndesmotic fixation remains a controversial topic, however most authors recommend fixation of the disrupted syndesmotic complex in unstable ankle fractures. There is no clear reference for the angle of syndesmotic fixation, historically 30° has been cited but recently refuted, with new and current literature. It is common practice to place 2 points of transyndesmotic fixation one with fixation placed at around 2 cm above the ankle joint and the second point approximately 3.5 cm above the plafond. Our hypothesis is that the ideal angle of transyndesmotic fixation is less than 30° and that the ideal angle changes when you move proximal from the 2-cm level to 3.5-cm level. This is based on cross-sectional anatomy as seen on weightbearing computerized tomography imaging. It is imperative to achieve adequate reduction of the syndesmosis to prevent instability and a malaligned ankle joint, as this can result in refractory pain and early onset of degenerative changes. We reviewed 50 weightbearing computerized tomography scans of the foot and ankle to identify what we call the adjusted syndesmotic fixation angle. Our review found adjusted syndesmotic fixation angle to be 19.7° with ranges of (8°-31°) at 2 cm and 24.8° with ranges of (14°-38°) at 3.5 cm above the tibial plafond. These values were statistically significant when compared to historically cited 30°. Our research concludes that the historically cited 30° angle is frequently not the ideal angle for syndesmotic fixation and actually is less.

Cheilectomy Combined With First Tarsometatarsal Joint Arthrodesis for Surgical Treatment of Midstage Hallux Rigidus Complicated by Medial Column Insufficiency: Prospective Evaluation of Outcomes.

The role of metatarsus primus elevatus and first ray hypermobility is under scrutiny with regard to the pathoanatomy of hallux rigidus. Regardless of the underlying biomechanical cause, there is a subset of patients with hallux limitus present with concomitant insufficiency of the medial column identified on clinical exam and lateral imaging as dorsal divergence of the first compared with the second metatarsal. While cheilectomy and decompression metatarsal osteotomy are commonly used to mitigate retrograde forces at the first metatarsophalangeal joint (MPJ) level, traditional hallux limitus procedures do not address more proximal deformity of the medial column. Although the authors prefer to treat this complex condition with cheilectomy combined with tarsometatarsal joint arthrodesis, there is a paucity of literature on this approach. A prospective cohort study of consecutive patients was therefore performed to assess outcomes. Ten patients (3 males, 7 females) and 11 feet (8 right and 3 left) met the inclusion criteria. Mean follow-up was 21.9 months (range 12 to 52). Average age was 50.4 years (range 28 to 61). The average preoperative ACFAS score of 49.6 (range 29 to 61) improved to 78 (range 51 to 92) at 10 weeks postoperatively and 85.4 (range 60 to 100) at 1 year postoperatively. By 1 year postsurgery, 9 of 10 patients (90%) described their satisfaction level as very satisfied, and 1 (10%) was somewhat satisfied.

Can We Abandon Saw Wedge Resection in Lapidus Fusion? A Comparative Study of Joint Preparation Techniques Regarding Correction of Deformity, Union Rate, and Preservation of First Ray Length.

The traditional joint preparation technique for Lapidus fusion involves wedge resection using a saw to achieve correction of intermetatarsal angular deformity. The main drawback of this approach is undesirable shortening of the first ray, which can predispose to second ray overload that may preclude the procedure for a subset of patients or may necessitate second metatarsal shortening osteotomy. The goal of this study was to determine whether a first ray length-preserving joint preparation technique (curette and bur) achieves equivalent correction of deformity and fusion rate without first ray shortening compared with the standard saw wedge resection technique. A retrospective review of consecutive cases from January 2007 to August 2014 identified 62 patients who underwent 65 Lapidus fusions for hallux valgus correction with crossed-screw fixation. All patients treated from 2007 to 2010 had saw wedge resection, whereas all patients treated from 2011 to 2014 had curette and bur joint preparation without use of a saw. The mean intermetatarsal angle correction was 9.06° (range 5° to 14.7°) in the saw wedge resection group and 8.11° (range 2.8° to 15.5°) in the curette and bur group, a difference that was not statistically significant. The mean amount of first ray shortening was -3.14 (range -6.1 to 0) mm in the saw wedge resection group and -0.86 (range -2.3 to 4.2) mm in the curette and bur group, a result that was statistically significant. Osseous union was confirmed radiographically at 10 weeks postoperatively in all cases. These findings suggest that first ray length can be preserved using a more conservative joint preparation technique regardless of preoperative deformity, without compromising correction of deformity or union rate.

Achilles Lengthening and Multiple Z-Plasty in Parallel for Correction of Toe Walking Associated With Burn Scar Equinus Contracture.

The literature is sparse regarding treatment of burn scar equinus contracture, with focus primarily on staged procedures, serial casting, and gradual correction using external fixation in combination with soft-tissue procedures. This case study describes a single-stage ambulatory approach for late-stage correction of burn scar equinus contracture associated with toe walking. A case report is presented of an 11-year-old male with focus on procedure selection, surgical technique, and 12-month follow-up results. Surgery involved a single-stage approach with open Achilles lengthening, in addition to multiple skin Z-plasty in parallel with immediate protected weightbearing to correct toe walking. Inadequate release of contracture was noted intraoperatively after Achilles lengthening. Full correction was achieved after converting the longitudinal incision into multiple Z-plasty in parallel, with full heel purchase at 2 weeks postoperatively. The patient was completely healed with pain-free range of motion at 6 weeks postoperatively. At 12 months postoperatively, he continued to ambulate normally without overcorrection or recurrence of deformity. This case study describes a late-stage, minimally invasive, single-stage approach to correction of burn scar equinus contracture. The surgical principles and technique are described. Allowance of immediate weightbearing was possible because all other burn wounds were healed at late-stage presentation that avoided the need for gradual correction with external fixation or serial procedures.

Surgical Outcomes After Minimally Invasive Release of Stroke-Related Equinovarus Contracture of the Foot and Ankle.

Cerebrovascular accident frequently causes spastic equinovarus contracture of the foot and ankle, for which traditional surgical correction involves tendon transfer, osteotomy, and hindfoot fusion, which can be challenging for patients after cerebrovascular accident. We prospectively assessed the efficacy of a minimally invasive, ambulatory approach to correct this complex deformity in 12 consecutive patients. Surgery included Achilles tendon lengthening, lengthening of the posterior tibial tendon, and flexor tenotomy of all 5 digits. The 10-cm visual-analog scale and the Bristol Foot Score were used to assess pain and subjective foot-related quality of life, respectively. The mean patient age was 61.5 ± 5.68 years, and the duration of follow-up was 29.3 ± 18.5 (range 12.2 to 63.3) months. All patients had a preoperative equinovarus foot structure and all had a rectus foot in weightbearing stance at the 1-year postoperative evaluation. Nine (75.0%) patients showed no residual or recurrent deformity, whereas 3 (25.5%) displayed incomplete release of digital contractures; all patients were treated with in-office flexor tenotomy. Preoperative maximum ankle dorsiflexion was ≤90° in 12 (100%) patients and >90° in 9 (75.0%) patients postoperatively. The mean visual-analog scale score decreased in 10 (83.3%) patients, although a statistically significant decrease was not observed (p = .0535). The Bristol Foot Score improved from 55.17 ± 11.10 preoperatively to 36.83 ± 13.26 postoperatively, and this improvement was statistically significant (p = .0022). These outcomes demonstrate the effectiveness of the minimally invasive, ambulatory surgical approach to spastic equinovarus contracture without identified patient harm.

Distal Syme Hallux Amputation for Tip of Toe Wounds and Gangrene Complicated by Osteomyelitis of the Distal Phalanx: Surgical Technique and Outcome in Consecutive Cases.

Distal hallux gangrene and neuropathic ulceration associated with digit deformity frequently result in osteomyelitis of the distal phalanx. Ideal treatment would involve limited resection to preserve function. We describe our surgical technique and retrospective results for distal Syme hallux amputation with plantar flap closure. An institutional review board-approved review was conducted on cases performed over 8 years. A total of 15 consecutive patients (16 digits) with hallux soft tissue loss who had undergone distal Syme hallux amputation were included. In each case, initial resection removed the distal hallux wound, nail bed, and distal phalanx. The proximal phalanx tip was remodeled, allowing margin biopsy and reduction of prominence. Of the 16 digits, 5 (31.3%) had hammertoe deformity and 1 (6.3%) was excessively long. Positive probe-to-bone status was identified in 8 of the 16 digits (50.0%). All 8 ulcers (100.0%) that probed to bone had histologic or culture results consistent with distal phalanx osteomyelitis. A proximal margin biopsy was taken in 12 of 16 digits (75.0%), and proximal phalanx osteomyelitis was observed in 4 of 12 proximal margin biopsies (33.3%). Two digits (12.5%) failed to heal. Three digits (18.8%) required a more proximal amputation, and the remaining 13 (81.3%) were found to be well-healed and functional at the final follow-up examination. The mean follow-up period was 27.6 (range 8 to 97) months. We have found distal Syme hallux amputation to be an effective treatment when used judiciously for distal hallux gangrene and osteomyelitis associated with neuropathic ulceration. This procedure permits bone biopsy for early diagnosis, confirmation of clean margins, removal of nonviable tissue and the abnormal toenail, and some deformity correction.

Combined Medial Column Arthrodesis with Open Reduction Internal Fixation of Central Column for Treatment of Lisfranc Fracture-Dislocation: A Review of Consecutive Cases.

Lisfranc fracture-dislocations can be devastating injuries with significant long-term sequelae with or without surgical intervention. The main goal of treatment is to minimize the common long-term complications including pain, progressive arch collapse, degenerative joint disease, hardware failure, and reoperation. Partial primary fusion involving the first, second, and third tarsometatarsal joints has become a common approach for primarily dislocation injuries, with open reduction and internal fixation (ORIF) favored for Lisfranc injuries involving fracture. ORIF commonly requires revision surgery for hardware removal or delayed fusion. Major revision creates hardship for the patient due to the prolonged recovery required, and even "simple" hardware removal can be traumatic to local nerve, artery, and tendon structures. A common injury pattern includes the findings of primary dislocation and instability of the first tarsometatarsal joint with oftentimes comminuted fracture to the second and third tarsometatarsal joints, which does not fit the standard surgical approach. We report a review of our preferred surgical approach consisting of medial column primary arthrodesis combined with central column ORIF and lateral column temporary pinning. We undertook an institutional review board-approved review of 35 consecutive Lisfranc injuries treated with this hybrid approach. Mean follow-up time was 22.14 ± 22.39 (range 2.5 to 84) months. All but 2 (5.71%) patients had radiographic evidence of union at 10 weeks. Complications included 3 with neuritis, 1 with medial column nonunion that was treated with a bone stimulator, and 1 with revision of second metatarsal nonunion. The present retrospective series highlights our experience with isolated primary fusion of the medial column in both subtle and obvious Lisfranc injuries.

Cotton Osteotomy in Flatfoot Reconstruction: A Review of Consecutive Cases.

The Cotton osteotomy or opening wedge medial cuneiform osteotomy is a useful adjunctive flatfoot reconstructive procedure that is commonly performed; however, the outcomes are rarely reported owing to the adjunctive nature of the procedure. The Cotton procedure is relatively quick to perform and effectively corrects forefoot varus deformity after rearfoot fusion or osteotomy to achieve a rectus forefoot to rearfoot relationship. Proper patient selection is critical because the preoperative findings of medial column joint instability, concomitant hallux valgus deformity, or degenerative joint disease of the medial column might be better treated by arthrodesis of the naviculocuneiform or first tarsometatarsal joints. Procedure indications also include elevatus of the first ray, which can be a primary deformity in hallux limitus or an iatrogenic deformity after base wedge osteotomy for hallux valgus. We undertook an institutional review board-approved retrospective review of 32 consecutive patients (37 feet) who had undergone Cotton osteotomy as a part of flatfoot reconstruction. All but 1 case (2.7%) had radiographic evidence of graft incorporation at 10 weeks. No patient experienced graft shifting. Three complications (8.1%) were identified, including 2 cases with neuritis (5.4%) and 1 case of delayed union (2.7%) that healed with a bone stimulator at 6 months postoperatively. Meary's angle improved an average of 17.75°, from -17.24°± 8.00° to 0.51°± 3.81°, and this change was statistically significant (p < .01). The present retrospective series highlights our experience with the use of the Cotton osteotomy as an adjunctive procedure in flatfoot reconstructive surgery.

Cotton Osteotomy in Flatfoot Reconstruction: A Case Report Highlighting Surgical Technique and Modified Incision to Protect the Medial Dorsal Cutaneous Nerve.

The Cotton osteotomy or opening wedge medial cuneiform osteotomy is a useful adjunctive flatfoot reconstructive procedure that is rarely performed in isolation. The Cotton procedure is relatively quick to perform and effectively corrects forefoot varus deformity after rearfoot fusion or osteotomy to achieve a rectus forefoot to rearfoot relationship. Proper patient selection is critical, because preoperative findings of medial column joint instability, concomitant hallux valgus deformity, or degenerative joint disease of the medial column might be better treated with arthrodesis of the naviculocuneiform or first tarsometatarsal joints. Procedure indications also include elevatus of the first ray, which can be a primary deformity in hallux limitus, or iatrogenic deformity after base wedge osteotomy in hallux valgus. We present the case of an adolescent patient who underwent flatfoot reconstruction, including Cotton osteotomy for correction of forefoot varus that was accentuated after double heel osteotomy. This case highlights our preferred procedure technique, including the use of a nerve-centric incision design. The use of an oblique dorsal medial incision is primarily intended to minimize the risk of trauma to the medial dorsal cutaneous nerve. At 20 months postoperatively for the right extremity and 12 months postoperatively for the left extremity, sensation remained intact, and the patient had not experienced any postoperative nerve symptoms. The patient had returned to playing sports without pain or restrictions.

Two-View Gravity Stress Imaging Protocol for Nondisplaced Type II Supination External Rotation Ankle Fractures: Introducing the Gravity Stress Cross-Table Lateral View.

Assessing ankle stability in nondisplaced Lauge-Hansen supination external rotation type II injuries requires stress imaging. Gravity stress mortise imaging is routinely used as an alternative to manual stress imaging to assess deltoid integrity with the goal of differentiating type II from type IV injuries in cases without a posterior or medial fracture. A type II injury with a nondisplaced fibula fracture is typically treated with cast immobilization, and a type IV injury is considered unstable and often requires operative repair. The present case series (two patients) highlights a standardized 2-view gravity stress imaging protocol and introduces the gravity stress cross-table lateral view. The gravity stress cross-table lateral view provides a more thorough evaluation of the posterior malleolus owing to the slight external rotation and posteriorly directed stress. External rotation also creates less bony overlap between the tibia and fibula, allowing for better visualization of the fibula fracture. Gravity stress imaging confirmed medial-sided injury in both cases, confirming the presence of supination external rotation type IV or bimalleolar equivalent fractures. Open reduction and internal fixation was performed, and both patients achieved radiographic union. No further treatment was required at 21 and 33 months postoperatively.

Medial and Lateral Plantar Artery Angiosome Rotational Flaps for Transmetatarsal and Lisfranc Amputation in Patients With Compromised Plantar Tissue.

Traditional incision techniques for midfoot amputation might not provide immediate soft tissue coverage of the underlying metatarsal and tarsal bones in the presence of a large plantar soft tissue defect. Patients undergoing transmetatarsal and Lisfranc amputation frequently have compromised plantar tissue in association with neuropathic ulcers, forefoot gangrene, and infection, necessitating wide resection as a part of the amputation procedure. Open amputation will routinely be performed under these circumstances, although secondary healing could be compromised owing to residual bone exposure. Alternatively, the surgeon might elect to perform a more proximal lower extremity amputation, which will allow better soft tissue coverage but compromises function of the lower extremity. A third option for this challenging situation is to modify the plantar flap incision design to incorporate a medial or lateral plantar artery angiosome-based rotational flap, which will provide immediate coverage of the forefoot and midfoot soft tissue defects without excessive shortening of the bone structure. A plantar medial soft tissue defect is treated with the lateral plantar artery angiosome flap, and a plantar lateral defect is treated with the medial plantar artery angiosome flap. Medial and lateral flaps can be combined to cover a central plantar wound defect. Incorporating large rotational flaps requires knowledge of the applicable angiosome anatomy and specific modifications to incision planning and dissection techniques to ensure adequate soft tissue coverage and preservation of the blood supply to the flap. A series of 4 cases with an average follow-up duration of 5.75 years is presented to demonstrate our patient selection criteria, flap design principles, dissection pearls, and surgical staging protocol.

Angle and Base of Gait Long Leg Axial and Intraoperative Simulated Weightbearing Long Leg Axial Imaging to Capture True Frontal Plane Tibia to Calcaneus Alignment in Valgus and Varus Deformities of the Rearfoot and Ankle.

The long leg axial view is primarily used to evaluate the frontal plane alignment of the calcaneus in relation to the long axis of the tibia when standing. This view allows both angular measurement and assessment for the apex of varus and valgus deformity of the rearfoot and ankle with clinical utility in the preoperative, intraoperative, and postoperative settings. The frontal plane alignment of the calcaneus to the long axis of the tibia is rarely fixed in the varus or valgus position because of the inherent flexibility of the foot and ankle, which makes patient positioning critical to obtain accurate and reproducible images. Inconsistent patient positioning and imaging techniques are commonly encountered with the long leg axial view for a variety of reasons, including the lack of a standardized or validated protocol. This angle and base of gait imaging protocol involves positioning the patient to align the tibia with the long axis of the foot, which is represented by the second metatarsal. Non-weightbearing long leg axial imaging is commonly performed intraoperatively, which requires a modified patient positioning technique to capture simulated weightbearing long leg axial images. A case series is presented to demonstrate our angle and base of gait long leg axial and intraoperative simulated weightbearing long leg axial imaging protocols that can be applied throughout all phases of patient care for various foot and ankle conditions.

Intraoperative Simulated Weightbearing Lateral Foot Imaging: The Clinical Utility and Ability to Predict Sagittal Plane Position of the First Ray in Lapidus Fusion.

The sagittal plane relationship of the first to second ray is a primary determinant of proper alignment in Lapidus midfoot fusion as assessed both clinically and on postoperative weightbearing lateral radiographs. The traditional approach to intraoperative fluoroscopic imaging allows for accurate assessment of fixation placement and intermetatarsal angle correction but only a crude evaluation of final sagittal plane alignment. Surgeons have used various methods in an attempt to load the foot during lateral imaging. This had led to inconsistent results and the potential for poor outcome. Skepticism exists regarding the ability of simulated weightbearing fluoroscopy to predict the final outcome, and evidence is lacking to support this practice. A prospective investigation was performed to assess the correlation of the first to second ray sagittal plane alignment as demonstrated on intraoperative simulated weightbearing lateral foot imaging studies and the 10-week postoperative lateral weightbearing radiograph. A consistent simulated weightbearing technique was used prospectively with 50 consecutive cases of Lapidus midfoot fusion with the goal of achieving parallel sagittal plane alignment of the first and second metatarsals with no divergence. Although 47 cases had no divergence and 3 had divergence with mild first ray elevatus, all 50 cases demonstrated a direct correlation between the intraoperative simulated and postoperative full weightbearing images. In conclusion, we believe the findings from our intraoperative imaging technique are a reliable predictor of first ray sagittal plane alignment in Lapidus midfoot fusion.

Two-Pin Fixation of Proximal Interphalangeal Joint Fusion for Hammertoe Correction.

Single-pin external Kirschner wire (K-wire) fixation has traditionally been a mainstay in proximal interphalangeal joint fusion for central hammertoe repair. Concerns over cosmesis, inconvenience, pin tract infection, hardware failure, nonunion, and early hardware removal have led to the development of implantable internal fixation devices. Although numerous implantable devices are now available and represent viable options for hammertoe repair, they are costly and often pose a challenge in the event removal becomes necessary. An alternative fixation option not typically used is a 2-pin K-wire fixation technique. The perceived advantage of obtaining 2 points of fixation compared with 1 across the fusion site is improved stability against the rotational and bending forces, thus decreasing the potential for pin-related complications. A retrospective assessment of 91 consecutive hammertoe repairs consisting of proximal interphalangeal joint fusion with 2-pin fixation in 60 patients was performed. The K-wires were removed at 6 weeks postoperatively, and the overall postoperative follow-up duration was 28.56 (range 1.40 to 86.83) months. Of the 91 digits, 89 (98%) did not encounter a complication postoperatively and 2 (2.20%) had sustained loosened or broken hardware. No postoperative infection was encountered. The low incidence of complications observed supports the 2-pin K-wire fixation technique as a low-cost and viable construct for proximal interphalangeal joint fusion hammertoe repair.

Complete Fifth Ray Amputation With Peroneal Tendon Transfer to the Cuboid: A Review of Consecutive Cases Involving Lateral Column Neuropathic Foot Ulceration and Osteomyelitis.

Nonhealing wounds along the fifth metatarsal associated with neuropathy and bone deformity frequently become complicated with osteomyelitis. Our surgical technique for complete fifth ray amputation with peroneal tendon transfer has been previously published. The present study evaluated the outcomes regarding success with initial healing and intermediate-term limb survival after this procedure, which is intended to resolve infection, remove bone deformity, heal and prevent recurrence of lateral column wounds, and maintain functional stability of the foot. An institutional review board-approved retrospective review of 21 consecutive cases was performed on patients who had undergone complete fifth ray amputation from August 2006 to September 2015. Comorbid conditions were assessed in relation to outcome. The typical stage 1 procedure involved complete fifth toe and metatarsal amputation, antibiotic bead placement, and preliminary wound closure. The stage 2 procedure was performed 2 weeks later and involved removal of the antibiotic beads, biopsy and remodeling of the cuboid, and peroneus longus tendon transfer to the cuboid. All cases involved ulceration along the fifth metatarsal. Of the 21 patients, 10 (47.6%) had undergone previous partial fifth ray amputation with recurrent ulceration at the residual metatarsal stump. Osteomyelitis of the fifth metatarsal was confirmed by bone culture and/or positive pathologic findings for osteomyelitis in 19 of 21 cases (90.5%). A total of 15 patients (71.4%) were completely healed at 10 weeks, and 10 patients (47.6%) required subsequent surgery, including 4 below-the-knee amputations and 1 Symes amputation. The average follow-up period was 37.0 (range 2.9 to 105) months. Despite the 10 patients (47.6%) requiring revision surgery, the limb salvage rate was 76.2% (16 of 21) at an average follow-up period of >3 years in this high-risk patient population.

Incidence and Clinical Significance of Heterotopic Ossification After Partial Ray Resection.

Heterotopic bone growth is a common finding after partial foot amputation that can predispose to recurrent wounds, osteomyelitis, and reamputation. Heterotopic ossification is the formation of excessive mature lamellar bone in the soft tissues adjacent to bone that is exacerbated by trauma or surgical intervention. The relevance of heterotopic ossification is dependent on its anatomic location. Its occurrence as a sequela of partial foot amputation can lead to prominence on the plantar aspect of the foot that can predispose the patient to recurrent neuropathic ulceration or preclude appropriate wound healing. Reulceration puts the high-risk patient who has already undergone local amputation at greater risk of recurrent infection and further amputation. The present study aimed to assess the incidence and risk factors for heterotopic ossification to further evaluate its role in partial foot amputation. A retrospective analysis of 72 consecutive patients who had undergone partial metatarsal resection was performed, with 90% of the cohort having peripheral neuropathy and 88% diabetes mellitus. Our findings revealed a heterotopic ossification incidence of 75% diagnosed radiographically. The initial onset of heterotopic ossification was not appreciated >10 weeks postoperatively. Ten patients (18.5%) exhibited heterotopic ossification-associated ulceration. The incidence of heterotopic ossification was 30% less in patients with peripheral vascular disease. These results indicate that heterotopic ossification is a common sequela of partial ray resection in an already high-risk patient population. The perioperative use of pharmacologic or radiation prophylaxis in an attempt to minimize amputation-related morbidity should be considered.