Midterm Outcomes of the INBONETM II Total Ankle Arthroplasty.

As the number of total ankle arthroplasties (TAA) performed continues to increase, understanding midterm outcomes can guide both implant selection and preoperative patient counseling. The purpose of this study was to investigate midterm results including the survival rate and reasons for revision for the INBONETM II TAA. Patients undergoing a primary TAA with the study implant and minimum of 4.6 years postoperative follow-up were reviewed from a prospectively collected database. The primary outcome was implant survival. Secondary outcomes included coronal plane radiographic alignment, evaluation for cysts and osteolysis, and failure mode when applicable. Patients were eligible for inclusion in this study if they had a minimum of 4.6-year follow-up TAA with the study implant. Eighty-five TAAs in 83 patients were eligible for inclusion; 75 TAA in 73 patients were included in the study. The mean duration of follow up was 6.2 ± 0.9 years (range 4.7-8.1 years). Thirty-six percent of the TAAs had a preoperative coronal plane deformity of at least 10°, and 12% of the TAAs had at least 20°. There were 6 (8%) implant failures that occurred at a mean 2.0 ± 1.4 years postoperatively. Eighty-one percent of the TAAs had no reoperation events in the follow-up period. Midterm outcomes at a minimum of 4.6 years postoperatively in patients undergoing a TAA using this implant demonstrates acceptable implant survival, an approximately 20% reoperation rate, and maintenance of coronal plane alignment.

Surgical Management of Charcot Arthropathy.

The historic management of Charcot foot arthropathy has consisted of immobilization until the active phase of the disease resolves, followed by longitudinal accomodative bracing of the acquired deformity. This historic management of Charcot foot arthropathy has not resulted in improved quality of life and has fostered interest in the surgical correction of the acquired deformity. Orthopaedic surgeons should understand the current indications for the surgical management of and the specific surgical techniques to correct acquired deformities in patients with Charcot foot and ankle disorders.

Lingual Malignant Peripheral Nerve Sheath Tumor in a Chinese Pug Dog.

A 9-year-old spayed/female Chinese Pug dog presented for evaluation of a mass located on the rostral aspect of the tongue. An incisional biopsy was acquired, submitted, and interpreted as a possible granular cell tumor based on hematoxylin and eosin, and periodic acid Schiff histopathologic staining characteristics. The diagnosis was supported by immunohistochemical evaluation that was positive for S-100, vimentin, and neuron-specific enolase. Based on the absence of mitotic figures in the incisional biopsy, a partial glossectomy was performed with gross margins of at least 1-cm. The excisional biopsy revealed significant features of malignancy, with neoplastic cells in close association with peripheral nerves, consistent with malignant peripheral nerve sheath tumor. Tumor-free margins were obtained, and the glossectomy had expected healing with no recurrence apparent 6-months following surgery.

Compressive Strength of Midfoot Fusion Nail vs Midfoot Fusion Bolt and Role of Subtalar Fusion in Midfoot Charcot Fixation Model.

BACKGROUND: Operative management of midfoot Charcot arthropathy often involves an extended midfoot arthrodesis with intramedullary bolts for fixation, a method called "beaming." Recently intramedullary nails have been introduced for the same indication, presumably providing stronger fixation. This study compares midfoot fusion nails to bolts with regard to stiffness and compressive ability. Additionally, we assessed how the addition of a subtalar fusion affects the construct. METHODS: Medial column fusions were performed on 10 matched cadaver foot specimens with either a midfoot fusion nail or bolt. Specimens underwent cyclical compression loading, and displacement was measured. Separately, compressive forces produced were compared between the 2 fixation constructs using a synthetic bone block model. Lastly, another 10 matched specimens with midfoot fusion nails were evaluated with or without subtalar fusions. RESULTS: No differences in stiffness were found in comparing matched specimens between nail vs bolt or comparing nail only without subtalar fusion (STF) vs nail with STF. The compressive force produced by the nail specimens was significantly and substantially greater than the bolted specimens (751.7 vs 139.0 N, P = .01). The accumulated height drop at the midfoot after cycling was 0.5 mm more in the nail group than in the bolt group (1.72 vs 1.22 mm, P = .008). The nail with STF group had greater initial height drop at the midfoot than the nail-only group (0.68 vs 0.34 mm, P = .035) with similar initial height drop at the ankle. However, there were no differences in strength among the matched pairs of midfoot nail-only vs midfoot nail with STF as measured by displacement after fatigue or maximum force at load to failure. CONCLUSION: The overall cadaveric comparisons between matched pairs of nails vs bolts, and nail-only vs nail with STF, did not provide noteworthy differences between the groups with regard to strength or stiffness. However, the compressive force of the midfoot fusion nail was far superior to the bolt in a synthetic bone model. These data provide valuable insight comparing implants used in Charcot midfoot arthrodesis.

Peroneus Brevis to Longus Tendon Transfer in the Treatment of Flexible Progressive Collapsing Foot Deformity: A Cadaveric Study.

BACKGROUND: Although operative treatment of the flexible progressive collapsing foot deformity (PCFD) remains controversial, correction of residual forefoot varus and stabilization of the medial column are important components of reconstruction. A peroneus brevis (PB) to peroneus longus (PL) tendon transfer has been proposed to address these deformities. The aim of our study was to determine the effect of an isolated PB-to-PL transfer on medial column kinematics and plantar pressures in a simulated PCFD (sPCFD) cadaveric model. METHODS: The stance phase of level walking was simulated in 10 midtibia cadaveric specimens using a validated 6-degree of freedom robot. Bone motions and plantar pressure were collected in 3 conditions: intact, sPCFD, and after PB-to-PL transfer. The PB-to-PL transfer was performed by transecting the PB and advancing the proximal stump 1 cm into the PL. Outcome measures included the change in joint rotation of the talonavicular, first naviculocuneiform, and first tarsometatarsal joints between conditions. Plantar pressure outcome measures included the maximum force, peak pressure under the first metatarsal, and the lateral-to-medial forefoot average pressure ratio. RESULTS: Compared to the sPCFD condition, the PB-to-PL transfer resulted in significant increases in talonavicular plantarflexion and adduction of 68% and 72%, respectively, during simulated late stance phase. Talonavicular eversion also decreased in simulated late stance by 53%. Relative to the sPCFD condition, the PB-to-PL transfer also resulted in a 17% increase (P = .045) in maximum force and a 45-kPa increase (P = .038) in peak pressure under the first metatarsal, along with a medial shift in forefoot pressure. CONCLUSION: The results from this cadaver-based simulation suggest that the addition of a PB-to-PL transfer as part of the surgical management of the flexible PCFD may aid in correction of deformity and increase the plantarflexion force under the first metatarsal. CLINICAL RELEVANCE: This study provides biomechanical evidence to support the addition of a PB-to-PL tendon transfer in the surgical treatment of flexible PCFD.

Nitinol Staple Use in Primary Arthrodesis of Lisfranc Fracture-Dislocations.

BACKGROUND: Primary arthrodesis of Lisfranc fracture-dislocations is a reliable treatment option, yet concerns remain about nonunion. Nitinol staple use has recently proliferated in midfoot arthrodesis. The purpose of this study is to examine the union rate of primary arthrodesis of acute Lisfranc fracture-dislocations treated with nitinol staples compared with traditional plate-and-screw fixation. The secondary objective is to assess the difference in operative times and reoperation rates. METHODS: Midfoot fracture-dislocations treated with primary arthrodesis by 7 foot and ankle orthopaedic surgeons were reviewed. Of 160 eligible patients, 121 patients (305 joints) met the required 4-month minimum radiographic follow-up. Radiographic outcomes were analyzed at the individual joint level. Each joint was classified as either staples alone (45 patients, 154 joints), staples plus plates and screws (hybrid) (45 patients, 40 joints), or plates and screws alone (31 patients, 111 joints). The primary outcome was arthrodesis union at each joint fused. RESULTS: Nonunion was more common (9.0%, 10/111) among joints fixed with plate and screws than with hybrid (2.5%, 1/40) or staples only (1.3%, 2/154) (P = .0085). Multivariable regression demonstrated that autograft use was independent associated with union (P = .0035) and plate-and-screw only fixation was an independent risk factor for nonunion (P = .0407). Median operating room and tourniquet times were shorter for hybrid (92 and 83 minutes) and staple only (67 and 63 minutes) constructs compared to plate-and-screw only fixation (105 and 95 minutes) (P ≤ .0001 and .0003). There was no difference in reoperation rates among patients with different fixation types. CONCLUSION: We found that use of nitinol compression staple and bone autograft in primary arthrodesis of Lisfranc and midfoot fracture-dislocations was associated with both improved union rates and shorter tourniquet and operative times compared to traditional plate-and-screw fixation techniques. LEVEL OF EVIDENCE: Level III, therapeutic.

Minimally invasive technique versus an extensile lateral approach for intra-articular calcaneal fractures.

BACKGROUND: The optimal method for treating intra-articular fractures of the calcaneus remains controversial. Extensile approaches allow excellent fracture exposure, but high rates of wound complications are seen. Newer minimally invasive techniques for calcaneus fracture fixation offer a potentially lower wound complication rate, but long-term clinical results are not available. The aim of this study was to compare the outcomes of intra-articular calcaneus fractures treated with open reduction and internal fixation via an extensile approach versus those with a minimally invasive sinus tarsi approach. METHODS: We performed a retrospective review of all intra-articular calcaneal fractures treated operatively between October 2005 and December 2008. A total of 112 fractures were found that met our inclusion criteria; 79 were treated with an extensile lateral approach and 33 via a minimally invasive approach based on surgeon preference. Chart and radiographic results were thoroughly reviewed on all 112 fractures, specifically for wound healing complications and the need for further surgeries within the study period. Additionally, all patients were contacted and asked to return for a research visit that included radiography, clinical examination, and quality of life questionnaires (Short Form 36 [SF-36], foot function index [FFI], visual analog scale [VAS] pain). A total of 47 of 112 (42%) patients returned for a research visit (31 extensile, 16 minimally invasive). RESULTS: The 2 groups were comparable with regard to demographics (age, follow-up, male to female ratio, tobacco use, diabetes, workers' compensation status). In the extensile group, 53% of fractures were Sanders II and 47% were Sanders III, whereas in the minimally invasive group 61% were Sanders II and 39% were Sanders III. The overall wound complication rate was 29% in the extensile group (9% required operative intervention) versus 6% in the minimally invasive group (P = .005) (none required operative intervention). Overall, 20% of the extensile group required a secondary surgery within the study period versus 2% in the minimally invasive group (P = .007). In the group of patients who returned for research visits, the average FFI total score was 31 in the extensile group versus 22 in the minimally invasive group (P = .21). The average VAS pain score with activity was 36 in the extensile group versus 31 in the minimally invasive group (P = .48). Overall, 84% of patients in the extensile group were satisfied with their result versus 94% in the minimally invasive group (P = .32). Both groups had 100% union rates, and no differences were noted in the final postoperative Bohler's angle and angle of Gissane. CONCLUSION: Clinical results were similar between calcaneal fractures treated with an extensile approach and those treated with a minimally invasive approach. However, the minimally invasive approach had a significantly lower incidence of wound complications and secondary surgeries. The minimally invasive approach was a valuable method for the treatment of intra-articular calcaneal fractures, with low complication rates and results comparable to those treated with an extensile approach. LEVEL OF EVIDENCE: Level III, retrospective comparative case series.

A clinical and radiographic comparison of two hardware systems used to treat jones fracture of the fifth metatarsal.

BACKGROUND: There is a broad variation in the type and size of screws used for Jones fractures. Therefore, a screw implant specifically designed for the operative treatment of a Jones fracture has been developed. The purpose of this retrospective study was to compare the clinical and radiographic results of patients treated with a screw specifically designed for this fracture to a group treated with a traditional screw. METHODS: Forty-seven patients underwent surgery (47 feet) for a Jones fracture between 1999 and 2007, performed by 4 foot and ankle fellowship-trained orthopaedic surgeons at one institution. Twenty-six patients (26 feet) were treated with the indication-specific screw (group I), while 21 patients (21 feet) were operated on with the traditional screw (group II). All patients were retrospectively reviewed for either radiographic signs of union or an adverse event. Radiographic parameters were evaluated by 2 independent observers, which included Torg's classification system (intramedullary sclerosis, cortical hypertrophy, periosteal reaction), hardware failure, with an endpoint of healing or nonunion. Of 47 patients, 40 were available for clinical follow-up, and functional outcomes with VAS pain scores at final follow-up visit were compared. Additional procedures (bone grafting), complications, and adverse events were recorded. The results were analyzed using Fisher's exact tests and independent t test with a significance level of .05. The average age of the patients was 43.8 years, with a mean clinical follow-up of 37 months (range of 6 to 105 months). RESULTS: Preoperative films were classified according to the Torg classification system and did not demonstrate any difference between group I and group II, with respect to the type of Jones fracture. There was no significant difference found between the 2 groups as related to fracture union, but there was a higher number of adverse events in group II as compared with group I (P = .03). The adverse events included 2 implant failures, 1 intraoperative fracture, and 1 symptomatic hardware, all requiring further surgical interventions. All adverse events occurred within an average of 2 months after surgery. Clinically, there were no statistically significant differences between the 2 systems in regard to limitations in activity, shoe-wear modifications, recovery time, satisfaction, and willingness to repeat the surgery. The VAS pain scales (0-100) were equivalent; average VAS pain of group II was reported as 9 (range, 0-33), as compared to the VAS pain of patients in group I averaging 11 (range, 0-47). CONCLUSIONS: In our retrospective series, comparing 2 differing instrumentation systems in treating Jones fractures, both groups were found to progress to radiographic union above 95%. Although there was a statistically greater number of adverse events in the traditional hardware system (group II), clinically both groups had similar outcomes with good results. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Outcomes After Hallux Interphalangeal Joint Arthrodesis.

BACKGROUND: Hallux interphalangeal joint arthrodesis (HIPJA) is indicated for a variety of pathologies. Despite high nonunion rates, techniques remain unchanged. The aim of this study is to examine nonunion and complication rates and describe risk factors for treatment failure. METHODS: A query of an institutional database was performed to identify all patients undergoing HIPJA procedure over a 10-year period. Records were reviewed to the procedure, evaluate patient factors, indications, and radiographic/clinical arthrodesis. Radiographic union was defined as 2 cortical continuations or bridging at the arthrodesis site, absence of hardware failure, and the absence of lytic gapping of the arthrodesis. Clinical fibrous union was defined as radiographic nonunion with painless toe range of motion and physical examination consistent with fusion across the interphalangeal joint. RESULTS: Two hundred twenty-seven primary HIPJA procedures were identified. Our cohort demonstrated a 25.5% nonunion rate (58/227) and 21.1% reoperation rate (48/227). Patients with diabetes were at higher risk for nonunion (P = .014), but no significant differences were identified based on smoking status or diagnosis of inflammatory arthritis. No difference was seen between implant groups: single screw, multiple screws, screw plus other fixation, nonscrew fixation. Patients with prior hallux metatarsophalangeal joint arthrodesis did not have a significantly higher nonunion rate than patients without prior first metatarsophalangeal joint arthrodesis. Patients diagnosed with radiographic nonunion were at higher risk for reoperation (P < .0001). CONCLUSION: Our cohort represents the largest single-center series of HIPJA procedures published to date. We found relatively high nonunion and reoperation rates with standard current techniques. LEVEL OF EVIDENCE: Level III, retrospective case series.

Prospective Clinical and Computed Tomography Evaluation of Calcaneus Fractures Treated Through Sinus Tarsi Approach.

Background: The traditional lateral extensile approach to the calcaneus allows for excellent visualization but is associated with high wound complication rates. The sinus tarsi approach has been shown to produce similar radiographic outcomes with much lower rates of wound complications. The purpose of this study is to prospectively determine clinical and radiographic outcomes in calcaneus fractures treated with a sinus tarsi approach. Methods: Twenty-nine patients with 30 calcaneus fractures underwent operative fixation through a sinus tarsi approach and were prospectively evaluated. Routine pre- and postoperative radiographs were obtained, in addition to computed tomography (CT) scans at 6 weeks and 12 months after surgery. Patient-reported outcomes including American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale (VAS) pain score, Veterans Rand 12-Item Health Survey (VR-12), and Foot Functional Index (FFI) were recorded. Patients were followed for a minimum of 1 year postoperation. Results: Twenty-one patients with 22 calcaneus fractures completed 1 year of follow-up. At 12 months postoperation, 20 of 22 patients (91%) had 0 to 2 mm of fracture displacement at the posterior facet on CT scans whereas 2 of 22 patients had 2 to 4 mm of fracture displacement. There was no significant change in posterior facet fracture displacement comparing 6-week and 12-month postoperative CT scans (P > .99). Mean postoperative Bohler angle was 26.1 degrees compared to 13.2 degrees preoperatively. All patients had complete union of fracture site. There were no major wound complications. Four of 22 patients (18.2%) had minor wound complications. AOFAS, FFI, and VAS pain scores improved postoperatively but were not found to correlate with Bohler angle or critical angle of Gissane. Conclusion: We found that in select patients excellent anatomic alignment and good clinical outcomes with low wound complication rates can be achieved when fixing calcaneus fractures through the sinus tarsi approach. Level of Evidence: Level II, prospective cohort study.

Complications, Reoperations, and Patient-Reported Outcomes Following a 2-Stage Revision Total Ankle Arthroplasty for Chronic Periprosthetic Joint Infections.

BACKGROUND: As total ankle arthroplasty (TAA) becomes more common, chronic periprosthetic joint infections (PJIs) will be encountered more frequently. No studies have reported on patient-reported outcomes following a 2-stage revision procedure for a chronic PJI after a TAA. The primary purpose of this study was to investigate postoperative clinical outcomes at a minimum of 2 years following a 2-stage revision TAA for chronic PJI. METHODS: Patients who underwent a 2-stage revision TAA for a chronic PJI (>4 weeks after a primary TAA) between January 2010 and December 2019 were eligible to be included in this study. Chronic PJI was defined as a sinus tract that directly communicated with the prosthesis or the same organism identified in ≥2 synovial fluid samples. Twelve patients were eligible to be included in this case series. One patient died prior to 2-year follow-up, which left 11 patients available for analysis. All 11 patients underwent reimplantation. The data were found not to be normally distributed; therefore, medians and interquartile ranges (IQRs) were reported. RESULTS: At a median of 3.0 years (IQR 2.0-4.0 years) following the second stage of their revision arthroplasty, the median Foot and Ankle Ability Measure (FAAM) Activities of Daily Living and Sports scores were 60.7 (IQR 52.4, 79.8) and 31.3 (IQR 9.4, 40.6), respectively. At final follow-up, 10 patients (90.9%) were ambulating with a TAA in place. Seven patients (63.6%) required a reoperation including 1 patient who underwent a below-knee amputation. CONCLUSION: Our study suggests that a 2-stage revision TAA may be an option for patients with a chronic PJI. However, patients who undergo a 2-stage revision TAA for a chronic PJI have lower than previously published 2-year FAAM scores and a high rate of reoperation. LEVEL OF EVIDENCE: Level IV, case series.

Locked versus nonlocked plate fixation for hallux MTP arthrodesis.

BACKGROUND: Dorsal plate fixation is used commonly for arthrodesis of the hallux first metatarsophalangeal (MTP) joint. Custom dorsal plates incorporating locking technology have been developed recently for applications in the foot to provide relative ease of application and theoretically superior mechanical properties. The purpose of this study is to compare the radiographic and clinical outcomes of patients undergoing hallux MTP joint arthrodesis using a locked plate, or a nonlocked plate. MATERIALS AND METHODS: We compared consecutive patients who underwent hallux MTP arthrodesis for a variety of diagnoses with either a precontoured locked titanium dorsal plate (Group 1) or a precontoured, nonlocked stainless steel plate (Group 2). All patients were evaluated with radiographs, visual analog pain scale, American Orthopaedic Foot and Ankle Society (AOFAS) hallux score, and a detailed patient satisfaction survey. RESULTS: There were 73 feet in Group 1 and 107 feet in Group 2. There was a trend toward a higher nonunion rate in Group 1 compared to Group 2. When considering only patients without rheumatoid arthritis (RA), the union rate was significantly higher in Group 2 compared to Group 1. Hardware failure and the overall complication rate was equivalent between the two Groups. CONCLUSION: As locked plate technology continues to gain popularity for procedures in the foot, it is important that clinical outcomes are reported. Locked titanium plates were associated with higher nonunion rates. Improved plate design, patient selection, and an understanding of plate biomechanics in this unique loading environment may optimize future outcomes for hallux MTP arthrodesis.

Open Reduction and Primary Subtalar Arthrodesis for Acute Intra-articular Displaced Calcaneal Fractures.

OBJECTIVE: To evaluate the rate of subtalar arthrodesis based on a computed tomography (CT) scan after open reduction and primary subtalar arthrodesis for acute, displaced, intra-articular calcaneal fractures. DESIGN: Retrospective chart review. SETTING: Single tertiary care practice. PATIENTS: A retrospective chart review was performed to identify patients who sustained an acute, displaced, intra-articular calcaneal fracture and underwent open reduction and primary subtalar arthrodesis. Thirty-five patients participated in the study. INTERVENTION: Each patient included in the study was treated with open reduction and primary subtalar arthrodesis. MAIN OUTCOME MEASURES: All patients were evaluated with CT for arthrodesis of the posterior facet of the subtalar joint, which was quantitated. Other outcome measures included radiographic parameters, the Veterans RAND Item Health Survey, and the Foot and Ankle Ability Measure. RESULTS: The median patient age was 47.8 years (range 21.5-79.5 years). The median patient follow-up was 34.4 months (range 4.6-104.1 months). The Sanders classification was as follows: 3% (1/35) type II, 40% (14/35) type III, and 57% (20/35) type IV. Based on a CT scan, primary subtalar union occurred in 94.3% (33/35) of patients. CONCLUSIONS: Open reduction and primary subtalar arthrodesis for acute, displaced, intra-articular calcaneus fractures has a high rate of union and good pain and function outcomes. It should be strongly considered for patients with significant cartilage injury and comminution of the posterior facet. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Cheilectomy With or Without Cryopreserved Amniotic Membrane-Umbilical Cord Allograft for Hallux Rigidus.

BACKGROUND: For hallux rigidus, dorsal cheilectomy remains a treatment option even with advances in interposition techniques and devices. Cheilectomy aims to alleviate dorsal impingement and improve pain and function as well as range of motion. Cryopreserved umbilical cord allograft, with properties to mitigate inflammation and scar formation, has theoretical benefit for improving outcomes following cheilectomy. In this first prospective randomized and blinded cheilectomy study reported, we aimed to compare outcomes between cheilectomy alone and cheilectomy with umbilical cord allograft. METHODS: Patients were randomized to cheilectomy alone (CA) or cheilectomy with cryopreserved umbilical cord (ie, amniotic membrane-umbilical cord [AM-UC]). Patients were evaluated with American Orthopaedic Foot & Ankle Society (AOFAS), Foot Function Index (FFI), and visual analog scale (VAS) pain outcomes collected preoperatively and at 6 months and 1 year postoperatively. In addition, radiographic range of motion data were collected using stress radiographs. Fifty-one patients (26 AM-UC, 25 CA) completed the study, with 5 bilateral surgeries in the AM-UC group and 2 in the CA group, totaling 31 and 27 feet, respectively. RESULTS: The AM-UC group had statistically significant improved AOFAS and FFI scores at 1 year compared with the CA group, but there was no difference at 6 months. There was no significant difference between groups for VAS-pain scores at any time point, but overall VAS-pain improved in both groups from preoperative values. There was no significant difference in range of motion (total arc) between groups and changes in range of motion (total arc) in both groups from preoperative to 1 year postoperative were small. CONCLUSION: We present the results of the first randomized and blinded prospective study of cheilectomy surgery patients. When appropriately selected, cheilectomy remains a good option for patients with symptomatic hallux rigidus. Cryopreserved umbilical cord is a potential adjuvant to cheilectomy, with 1-year results showing improvements in functional outcome scores. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Radiographic analysis of proximal interphalangeal joint arthrodesis with an intramedullary fusion device for lesser toe deformities.

BACKGROUND: Lesser toe deformities are frequent and bothersome conditions. Many options exist for the treatment of hammertoes and clawtoes. The purpose of this study was to review our experience with the use of an intramedullary fusion device. MATERIALS AND METHODS: An IRB approved retrospective review was performed to identify 38 toes in 27 patients treated with the StayFuse (Nexa Orthopaedics) device with a mean followup of 31 months. The indications for surgery were primary deformity in 12 toes and recurrent deformities in 26 toes. RESULTS: Union occurred in 23 of 38 (60.5%). The union rate was nine of 12 for primary procedures and 53.8% (14/26) for revisions. Coronal PIP alignment demonstrated no change in 33 of 38 cases (86.8%) and changed in five of 38 (13.2%). Sagittal PIP alignment demonstrated no change in 36 of 38 cases (94.7%), and changed in 2/38 (5.3%). Including nonunion, the overall complication rate was 55.3% (21/38) (15 nonunions; three hardware failures (two (bent) not requiring intervention and one (broke) leading to a rotational deformity requiring revision), one intraoperative fracture (without sequelae), one requiring MP surgery, and one requiring a larger implant. The index surgery for all three of the patients that required a second surgery was for a recurrent deformity. All three patients requiring a second surgery occurred in the nonunion group. CONCLUSION: The StayFuse intramedullary fusion device was efficacious in maintaining PIP alignment in the treatment of lesser toe deformities with a relatively low reoperation rate at mid-term followup.

Review of 107 hallux MTP joint arthrodesis using dome-shaped reamers and a stainless-steel dorsal plate.

BACKGROUND: The purpose of this study was to retrospectively review the results of patients treated with hallux MTP joint arthrodesis using dome-shaped reamers for joint preparation and a precontoured dorsal stainless steel plate for internal fixation. MATERIALS AND METHODS: A series of 145 patients (155 feet) were identified. Postoperative evaluation included weightbearing radiographs, physical examination, and chart review. Outcomes were assessed with a pain visual analog scale, AOFAS hallux score, as well as a detailed questionnaire and a subjective satisfaction survey. RESULTS: Ninety-eight patients (107 feet) met the criteria for the study. The mean followup was 61 weeks. Revision cases accounted for 18.7% (20/107). Rheumatoid arthritis (RA) was present in 32.7% (35/107). The average postoperative AOFAS hallux score was 79.7 and pain VAS was 19. The average pre- and postoperative hallux valgus angle was 26.5 and 12.3 degrees, respectively (p < 0.05). Eighty-nine of 107 patients (83.1%) reported good to excellent results at final followup. Discomfort related to prominence of the plate occurred in 14.9% (16/107). The nonunion rate was 12.1% (13/107). The nonunion rate for patients with/without RA was 22.9% (8/35) and 6.9% (5/72), respectively (p < 0.05). Patients with a nonunion noted more hardware related pain than those with a union (p < 0.05). CONCLUSION: First MTP joint arthrodesis using this technique achieves a high union rate. RA patients have a lower union and higher complication rate.

Surgical outcome following tibialis anterior tendon repair.

BACKGROUND: Tibialis anterior tendon rupture is an uncommon injury that can cause significant functional deficit. Recent series have supported surgical reconstruction in younger, more active patients. We investigated our clinical outcomes of patients having undergone surgical management of tibialis anterior tendon ruptures. MATERIALS AND METHODS: Fifteen tibialis anterior tendon ruptures in 14 patients were retrospectively reviewed after surgical management. Five had primary repair, while 10 had tendon transfers. Average age at time of surgery was 70.6 years with an average followup of 27.2 months. Patients were evaluated with American Orthopaedic Foot and Ankle Society (AOFAS) and SF-36 clinical outcome scores. Strength measurements utilizing a dynamometer and range of motion (ROM) were documented on the operative and non-operative ankles. Patient satisfaction surveys were performed. RESULTS: Average postoperative AOFAS hindfoot score was 88.8 and SF-36 score was 76.4. There was a statistically significant difference in average dorsiflexion strength of 21.8 lbs/in(2) on the operative side and 28.8 lbs/in(2) on the non-operative limb, and in dorsiflexion ROM of patients that received a gastrocnemius recession. There was no statistically significant difference between primary tendon repair versus tendon transfer groups nor plantarflexion strength or ROM among any group. Patient surveys revealed that seven patients were completely satisfied, six had minor reservations, and one had major reservations. There were no complications. CONCLUSION: This study supports the surgical repair or reconstruction of the tibialis anterior tendon ruptures to restore functional strength and ROM.

Cavovarus: Fifth Metatarsal Fractures and Revision Open Reduction Internal Fixation.

Proximal fifth metatarsal fractures, specifically zones 2 and 3, are often treated surgically to lower risk of nonunion and shorten recovery and rehabilitation period. However, even with the advancement of surgical strategies, techniques, and implants, nonunions remain a challenge. One notable risk factor for a primary or recurrent Jones fracture is the cavovarus foot. If this is identified and a recurrent fifth metatarsal base fracture occurs, the surgeon should strongly consider addressing the malalignment in addition to revision open reduction internal fixation. This article provides guidelines for treatment of a recurrent fracture or nonunion with a concomitant cavovarus foot deformity.

Evaluation of the hallux morbidity of single-incision flexor hallucis longus tendon transfer.

BACKGROUND: Achilles tendinosis and chronic Achilles tendon ruptures are relatively frequently encountered by orthopaedic surgeons. One treatment for patients who fail to respond to conservative management involves augmentation of the repair with transfer of the flexor hallucis longus (FHL), using either a single-incision or double-incision technique. Despite the frequency of this procedure, little is known about the associated donor morbidity. We report the effects of the single-incision technique on hallux function. MATERIALS AND METHODS: We retrospectively reviewed 48 patients who underwent a single-incision FHL tendon transfer for chronic Achilles tendon rupture or Achilles tendinosis. Twenty-two patients (mean followup, 28 months) completed the study. The average age was 56 years. Outcome measures included the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal (MTP) joint and interphalangeal (IP) joint scores, the Health Related Quality of Life Measures Short Form (SF-36). Also, the average of two pedobarographic measurements of both feet and strength testing of the FHL of both feet were recorded. RESULTS: Decreased distal phalangeal pressure and FHL weakness were demonstrated (p < 0.05). No difference was noted in plantar pressure of the first or second metatarsal head. The high score on the AOFAS hallux MTP-IP scale demonstrated improved patient forefoot function after FHL transfer through a single-incision technique. CONCLUSION: Flexor hallucis longus tendon transfer using a single-incision technique results in decreased flexion power at the IP joint as demonstrated by decreased distal phalangeal pulp pressure; however, this appears to be a laboratory finding as patient function remains high.

Clinical Outcomes and Complications of Midfoot Charcot Reconstruction With Intramedullary Beaming.

BACKGROUND:: The purpose of this study was to examine the clinical outcomes and complications of patients with midfoot Charcot managed with midfoot osteotomy, realignment arthrodesis, and stabilization using intramedullary beams. METHODS:: Consecutive patients with midfoot Charcot treated at a tertiary-care foot and ankle center from January 2013 to July 2016 who underwent corrective osteotomy with internal beam fixation were identified; 25 patients were included in the final analysis. Patients with a minimum 1-year follow-up were evaluated with physical examination, weightbearing radiographs, and patient-reported outcome measures. The primary outcome measure was defined as restoration of a stable, plantigrade, ulcer-free foot. Median age was 58 years, median BMI was 32, and 80% were diabetic (75% insulin-dependent). RESULTS:: An ulcer-free, stable, plantigrade foot was obtained in 84% of patients. The radiographic lateral and anteroposterior Meary angle medians improved 9° and 15°, respectively, from preoperative to final postoperative weightbearing measurements ( P < .001 and P = .02). Overall, 46% of midfoot osteotomies were united on final radiographs at a median 18-month radiographic follow-up. Deep infection developed in 6 (24%) patients. The presence of a preoperative ulcer was found to be predictive of postoperative infection (P = .04); all 6 deep infections occurred in patients with preoperative ulceration. Four (16%) patients progressed to amputation at a mean 15 postoperative months, all for deep infection. CONCLUSION:: Midfoot Charcot reconstruction with intramedullary beaming allowed for restoration of an ulcer-free, plantigrade foot in most patients, but the complication rates were high, especially in patients with preoperative ulceration. LEVEL OF EVIDENCE:: Level IV, retrospective case series.