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Journal Cover   Foot & Ankle International
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   Hybrid Journal Hybrid journal (It can contain Open Access articles)
   ISSN (Print) 1071-1007
   Published by Sage Publications Homepage  [821 journals]
  • Prospective, Multicenter Evaluation of Allogeneic Bone Matrix Containing
           Viable Osteogenic Cells in Foot and/or Ankle Arthrodesis
    • Authors: Jones, C. P; Loveland, J, Atkinson, B. L, Ryaby, J. T, Linovitz, R. J, Nunley, J. A.
      Pages: 1129 - 1137
      Abstract: Background: Cellular bone allograft (CBA) possesses osteogenic, osteoinductive, and osteoconductive elements essential for bone healing. The purpose of this study was to assess the safety and effectiveness of CBA in foot and/or ankle arthrodeses. Methods: A prospective, multicenter, open-label clinical trial using CBA was performed. At 6 weeks and at 3, 6, and 12 months, imaging was performed and the subject’s pain, function, and quality of life (QOL) status (Visual Analog Scale, American Orthopaedic Foot & Ankle Society Hindfoot Scale, and the Short Form 36) were recorded. The per protocol population consisted of 92 patients at 6 months and 76 patients at 12 months, with 153 and 129 total arthrodeses, respectively. Results: At 6 months, fusion rates were 68.5% for all patients and 81.1% for all joints; at 12 months, rates were 71.1% and 86.8%, respectively. Certain high-risk subjects (eg, with diabetes or obesity) had fusion rates comparable to those of normal patients. Statistically significant improvements in pain, function, and QOL were observed, and fusion correlated with both function and QOL outcomes at 6 and 12 months. There were no adverse events attributable to CBA. Conclusion: Fusion rates using CBA were higher than or comparable to fusion rates with autograft that have been reported in the recent literature, and CBA fusion rates were not adversely affected by several high-risk patient factors. CBA was a safe and effective graft material to achieve fusion in patients with compromised bone healing and may provide an effective autograft replacement for foot and/or ankle arthrodeses. Level of Evidence: Level II, prospective study.
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715586181
      Issue No: Vol. 36, No. 10 (2015)
  • Complications After Popliteal Block for Foot and Ankle Surgery
    • Authors: Anderson, J. G; Bohay, D. R, Maskill, J. D, Gadkari, K. P, Hearty, T. M, Braaksma, W, Padley, M. A, Weaver, K. T.
      Pages: 1138 - 1143
      Abstract: Background: A popliteal nerve block is a common analgesic procedure for patients undergoing surgery on their knee, foot, or ankle. This procedure carries less risk in a surgical setting compared with other forms of anesthesia such as a spinal block. Previous reports demonstrated few to no complications with the use of this nerve block, but it is unclear whether these data are consistent with the recent increase in use of this analgesic procedure for lower extremity surgery. Methods: Retrospectively, a busy orthopedic foot and ankle practice performed a chart review examining for postoperative neuropathic complications possibly related to the popliteal nerve block. The 1014 patients who had undergone a popliteal block for foot and/or ankle orthopedic surgery were analyzed for short and long-term neuropathic complications. The collected data consisted of tourniquet time, pressure, and location as well as the method of finding the fossa nerve, adjuncts used, and patient medical history. Data were analyzed using chi-square, Fisher’s exact, and t tests for analysis with a significance value of P < .05. Result: Of these 1014 patients, 52 patients (5%) developed deleterious symptoms likely resulting from their popliteal block, and 7 (0.7%) of these were unresolved after their last follow-up. No immediately apparent underlying causes were determined for these complications. Conclusion: The frequency of a neuropathic complication following a popliteal nerve block was notably higher in the early postoperative period than indicated in the past. The proportion of patients with unresolved neuropathic symptoms at last follow-up is comparable to that previously reported in the literature. Level of Evidence: Level IV, retrospective case series.
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715589741
      Issue No: Vol. 36, No. 10 (2015)
  • Impact of Diabetes on Outcome of Total Ankle Replacement
    • Authors: Gross, C. E; Green, C. L, DeOrio, J. K, Easley, M, Adams, S, Nunley, J. A.
      Pages: 1144 - 1149
      Abstract: Background: As the incidence of diabetes mellitus (DM) grows, managing patients with diabetes and concomitant ankle arthritis poses a challenging clinical dilemma. While diabetes is known to be a risk factor for complications relating to open reduction and internal fixation of ankle fractures, it is unclear if DM is a risk factor for negative outcomes after total ankle replacement (TAR). Methods: We retrospectively identified a consecutive series of 813 primary TARs performed between 2002 and November 2013 that had a minimum follow-up of 1 year. Within that larger group, we identified 50 patients with DM and used a control group without DM for comparison (n = 55). Clinical outcomes including wound issues, infection rates, complications, and failure rates were then compared. Functional outcomes, including American Orthopaedic Foot & Ankle Society hindfoot score, Short Form–36 (SF-36), Short Musculoskeletal Function Assessment, Foot and Ankle Disability Index, and visual analog scale, were also compared. Median patient follow-up was 2.3 years in the DM group and 3.1 years in the control group (P = .239). Results: The body mass index, age, preoperative American Society of Anesthesiologists (ASA) grading, and smoking history in the DM were significantly higher than in the control group. While 5 patients (10%) in the DM group had secondary operations related to the TAR, no patients had a superficial or deep infection. Eight patients (14.5%) in the control group had secondary operations, including 1 patient who needed a flap. There was no statistical differences in secondary operations (P = .562), revisions (P = .604), or failure rates (P = .345). For both the diabetes and control groups, all functional outcome scores except SF-36 General Health significantly improved at 1 year postoperatively; these improvements were maintained at most recent follow-up. There was no statistically significant difference between the groups regarding functional outcomes except that at 1 year, the magnitude of improvement in SF-36 General Heath was significantly better in the control group. Conclusions: Total ankle arthroplasty appears to be an effective and safe means for providing pain relief and improving function in patients with diabetes and ankle arthritis. While patients with DM were heavier and had worse ASA preoperative grades, they did not have a significantly different complication or infection rate. Level of Evidence: Level III, retrospective comparative study.
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715585575
      Issue No: Vol. 36, No. 10 (2015)
  • Talofibular Bony Impingement in the Ankle
    • Authors: Ahn, J.-Y; Choi, H.-J, Lee, W.-C.
      Pages: 1150 - 1155
      Abstract: Background: Talofibular bony impingement has not previously been reported, since it is difficult to detect on plain radiograph, similar to the spur on the anterior border of the medial malleolus and anterior portion of the medial talar facet. We hypothesized that talofibular bony impingement can cause limited dorsiflexion of the ankle. The aim of this study was to evaluate talofibular bony impingement as a distinct form of impingement that limits dorsiflexion of the ankle. Methods: This study included 20 consecutive patients (21 ankles) with talofibular impingement and 19 consecutive patients (19 ankles) with lateral ankle instability without talofibular impingement. Presence or absence of talofibular impingement was confirmed under direct intraoperative visualization. Dorsiflexion before and after excision of the impinging spurs was measured. Findings on plain radiographs and computed tomography were compared between the groups. Pre- and postoperative clinical assessments were done with Foot Function Index, visual analog scale for pain, and American Orthopaedic Foot & Ankle Society ankle-hindfoot score at a mean follow-up of 1.4 years. Results: After removal of the bony impingement, the range of dorsiflexion increased by a mean 7.9 degrees (range, 2.5 to 11.0 degrees) in the impingement group. The mean distance between the fibula and lateral process of the talus on weight- bearing anteroposterior radiograph of the ankle was 1.2 mm (range, 0 to 4.5) in the impingement group and 3.2 mm (range, 1 to 4.5) in the control group. On axial computed tomography image, bony protrusion of the lateral process of the talus was frequently present in the impingement group, and the mean amount of protrusion was more than that of the control group. Clinical findings improved overall. Conclusions: Talofibular impingement was a cause of limited dorsiflexion, and the diagnosis was confirmed intraoperatively. Level of Evidence: Level III, retrospective comparative study.
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715586025
      Issue No: Vol. 36, No. 10 (2015)
  • Survival Analysis of the Single- and Double-Coated STAR Ankle up to 20
           Years: Long-Term Follow-up of 324 Cases From the Swedish Ankle Registry
    • Authors: Henricson, A; Carlsson, A.
      Pages: 1156 - 1160
      Abstract: Background: The Scandinavian Total Ankle Replacement (STAR) has been used widely in Europe and more recently in the United States. We studied the results of the single-coated and the double-coated STAR with long-term follow-up. Methods: All STARs (n = 324) used in Sweden (first implanted in 1993) were included. Prosthetic survival was estimated according to Kaplan-Meier. Results: The 14-year survival of the single-coated STAR was 0.47 (95% confidence interval [CI], 0.38-0.66), and the 12-year survival of the double-coated STAR was 0.64 (95% CI, 0.57-0.71). Women younger than 60 years with osteoarthritis had a statistically significantly higher risk of revision than men and than patients with other diagnoses. Conclusion: The long-term results of the STAR prosthesis are not encouraging. The results seem to deteriorate by time. Level of Evidence: Level IV, retrospective case series.
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715579863
      Issue No: Vol. 36, No. 10 (2015)
  • Letter Regarding: Survival Analysis of the Single- and Double-Coated STAR
           Ankle up to 20 Years: Long-term Follow-up of 324 Cases From the Swedish
           Ankle Registry
    • Authors: Mann, R. A; Coughlin, M, Palanca, A. A.
      Pages: 1161 - 1161
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715609056
      Issue No: Vol. 36, No. 10 (2015)
  • Response to "Letter Regarding: Survival Analysis of the Single- and
           Double-Coated STAR Ankle up to 20 Years: Long-term Follow-up of 324 Cases
           From the Swedish Ankle Registry"
    • Authors: Henricson, A; Carlsson, A.
      Pages: 1162 - 1162
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715608778
      Issue No: Vol. 36, No. 10 (2015)
  • Radiographic Outcomes of Preoperative CT Scan-Derived Patient-Specific
           Total Ankle Arthroplasty
    • Authors: Hsu, A. R; Davis, W. H, Cohen, B. E, Jones, C. P, Ellington, J. K, Anderson, R. B.
      Pages: 1163 - 1169
      Abstract: Background: Preoperative computer navigation and patient-specific instrumentation have had promising results in total knee arthroplasty and in a previous cadaveric total ankle arthroplasty (TAA) study. Potential benefits of patient-specific guides include improved implant alignment and decreased surgical time. The purpose of this retrospective case series was to evaluate the accuracy, reproducibility, and limitations of TAA tibia and talar implant placement and radiographic alignment using preoperative computed tomography (CT) scan–derived instrumentation in a clinical setting. Methods: Between 2012 and 2014, 42 consecutive TAA cases in 42 patients using preoperative CT scan–derived patient-specific plans and guides (PROPHECY, Wright Medical Technology, Memphis TN) were reviewed from a single center of foot and ankle fellowship–trained orthopaedic surgeons. TAA implants used included 29 intramedullary referencing implants (INBONE II, Wright Medical Technology) and 13 low-profile tibia and talar resurfacing implants (Infinity, Wright Medical Technology). All patients had standardized preoperative CT scans before surgery that were used to create custom surgical plans and 3-dimensional solid cutting guides and models. All patients had a minimum 3-month follow-up with weightbearing postoperative radiographs. Patient demographics were recorded, and coronal and sagittal alignments were compared among weightbearing preoperative radiographs, CT scan–derived surgical plans, and weightbearing postoperative radiographs using a digital picture archiving and communication system. Results: Average age for all patients was 63 ± 9 years, with a body mass index of 29.8 ± 5.9. Average total surgical time for all TAAs was 100 ± 11 minutes, with Infinity TAAs taking less time than INBONE II TAAs (92 vs 104 minutes; P < .05). Average preoperative coronal alignment was 1.9 degrees varus ± 6.4 (range, 14 degrees valgus to 10 degrees varus). Postoperative weightbearing alignments for all TAA cases were within ±3° of the predicted coronal and sagittal alignments from the CT scan–derived surgical plans. There were no significant differences in pre- or postoperative weightbearing alignments between INBONE II and Infinity TAA cases. Neutral coronal and sagittal alignments were obtained for all TAA cases regardless of preoperative deformity. Patient-specific surgical plans were accurate to within 1 size for tibia and talar implants used. Surgical plans predicted the actual tibia implant size used in 100% of INBONE II cases and 92% of Infinity cases. Plans were less accurate for talar implants and predicted the actual talar implant size used in 76% of INBONE II cases and 46% of Infinity cases. In all cases of predicted tibia or talar size mismatch, surgical plans predicted 1 implant size larger than actually used. Conclusions: Results from this study provide early clinical evidence that preoperative CT scan–derived patient-specific surgical plans and guides can help provide accurate and reproducible TAA radiographic alignments. Talar implant sizing was not as accurate due to individual surgeon preference regarding the extent of gutter debridement. Similar to other modern computer navigation and patient-specific instrumentation systems, final coronal and sagittal alignments were within 3 degrees of the predicted surgical plans, and sizing was accurate within 1 implant size. Future studies are warranted to investigate the clinical and functional implications of patient-specific TAA and the overall cost-effectiveness of this technique. Level of Evidence: Level IV, retrospective case series.
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715585561
      Issue No: Vol. 36, No. 10 (2015)
  • Factors Affecting the Outcomes of Uncomplicated Primary Open Ankle
    • Authors: Chalayon, O; Wang, B, Blankenhorn, B, Jackson, J. B, Beals, T, Nickisch, F, Saltzman, C. L.
      Pages: 1170 - 1179
      Abstract: Background: The objective of this study was to identify factors influencing operative outcomes in straightforward, uncomplicated open ankle fusions. Methods: We reviewed all primary open ankle fusions conducted at 1 institution over an 11-year period to identify straightforward, uncomplicated open ankle fusions. Inclusion required a minimum of 6 months follow-up. Patients were excluded for neuropathic arthropathy, insensate limb, failed total ankle replacement, simultaneous arthrodesis of the subtalar joint, or fusions performed within 1 year of injury to salvage failed fixation and painful function due to (1) open fractures, (2) segmental bone loss greater than 1 cm, (3) infection, or (4) talar body fractures. The primary outcome variable was radiographic union at 6 months. Other operative complications were analyzed as secondary outcomes. Five hundred twenty-eight ankle fusion surgeries were performed on 440 patients at 1 institution during the study period. Two hundred fifteen surgeries met inclusion/exclusion eligibility criteria for uncomplicated open ankle fusions. Results: The overall union rate was 91%. In this cohort of uncomplicated open ankle fusions, bivariate analysis over a broad range of potential factors and further focused multivariate analysis found that nonunion was more than 3 times more likely to occur after previous subtalar fusion, and 2 times more likely to occur in patients with preoperative varus ankle alignment. The rate of reoperation was 19%, with nonunion revision as the leading reason, followed by hardware removal and incision and drainage for presumed infection. Diabetes was not a significant risk factor of either deep or superficial infection. Conclusion: Open ankle fusion failed in 9% of uncomplicated ankles with arthritis. Patients who had an open ankle fusion done after previous subtalar joint fusion, as well as those who had preoperative varus ankle alignment, had a significantly higher rate of nonunion. Level of Evidence: Level III, retrospective comparative study.
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715587045
      Issue No: Vol. 36, No. 10 (2015)
  • Allograft Reconstruction of Chronic Tibialis Anterior Tendon Ruptures
    • Authors: Huh, J; Boyette, D. M, Parekh, S. G, Nunley, J. A.
      Pages: 1180 - 1189
      Abstract: Background: Chronic ruptures of the tibialis anterior tendon are often associated with tendon retraction and poor-quality tissue, resulting in large segmental defects that make end-to-end repair impossible. Interpositional allograft reconstruction has previously been described as an operative option in these cases; however, there are no reports of the clinical outcomes of this technique in the literature. Methods: Eleven patients with chronic tibialis anterior tendon ruptures underwent intercalary allograft recon-struction between 2006 and 2013. Patient demographics, injury presentation, and details of surgery were reviewed. Postoperative outcomes at a mean follow-up of 43.8 (range, 6-105) months included the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score, Short Form–12 (SF-12) physical health score, Lower Extremity Functional Score (LEFS), visual analog scale (VAS) pain rating, dorsiflexion strength, gait analysis, and complications. Results: The average postoperative dorsiflexion strength, as categorized by the Medical Council grading scale, was 4.8 ± 0.45. The average postoperative VAS score was 0.8 ± 1.1. The average LEFS was 66.9 ± 17.2, SF-12 physical health score was 40.1 ± 14.4, and AOFAS score was 84.3 ± 7.7. One complication occurred, consisting of transient neuritic pain in the superficial peroneal nerve distribution. There were no postoperative infections, tendon reruptures, reoperations, or allograft-associated complications. Conclusion: Allograft reconstruction of chronic irreparable tibialis anterior tendon ruptures yielded satisfactory strength, pain, and patient-reported functional outcomes. This technique offers a safe and reliable alternative, without the donor site morbidity associated with tendon transfer or autograft harvest. Level of Evidence: Level IV, retrospective case series.
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715589006
      Issue No: Vol. 36, No. 10 (2015)
  • Rate of Union After Segmental Midshaft Shortening Osteotomy of the Lesser
    • Authors: DeSandis, B; Ellis, S. J, Levitsky, M, O'Malley, Q, Konin, G, O'Malley, M. J.
      Pages: 1190 - 1195
      Abstract: Background: Current literature reports excellent rates of union following various lesser metatarsal osteotomy techniques. However, it is our experience that segmental midshaft shortening osteotomies heal very slowly and have a greater potential for nonunion than has previously been reported. The purpose of this study was to assess union rates and report the time required for segmental midshaft shortening osteotomies to achieve radiographic union. Methods: We reviewed the charts and postoperative radiographs of 58 patients (representing 91 osteotomies) who underwent segmental midshaft shortening osteotomies with internal fixation between January 2009 and December 2013. Radiographs were reviewed to determine when union was achieved. Union was defined as the bridging of 2 or more cortices in the anteroposterior, lateral, and oblique radiographic views. Osteotomies were classified as delayed union if they were not healed at 3 months postoperatively and nonunions if they were not healed at 6 months postoperatively. Results: Overall, 27 of 91 osteotomies met our radiographic classification of union and were healed by 3 months (29.7%). Sixty-nine of the 91 osteotomies healed by 6 months (75.8%) and were considered delayed unions. Twenty-two osteotomies were not healed yet and therefore were considered nonunions (24.2%). Of the 22 nonunions, 7 healed in an additional 2 months (8 months) for an overall healing percentage of 83.5%, (76 of 91). By 10 months, 6 more nonunions were healed (overall healing percentage of 90.1%, 82 of 91). Three additional nonunions went on to heal by 12.9 months, yielding a final union rate of 93.4% (85 of 91), while 6 were still considered nonunions (6.6%). Conclusion: We report that a significant percentage of segmental midshaft metatarsal shortening osteotomies experienced delayed unions and nonunions. These findings contrast those previously reported in the literature that metatarsal osteotomies have very low nonunion rates. These results support our hypothesis that these osteotomies require a prolonged amount of time to achieve bony healing and that they have a higher tendency to develop delayed and nonunions than previously reported. Level of Evidence: Level IV, retrospective case series.
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715585560
      Issue No: Vol. 36, No. 10 (2015)
  • Quality and Utility of Immediate Formal Postoperative Radiographs in Ankle
    • Authors: Miniaci-Coxhead, S. L; Martin, E. A, Ketz, J. P.
      Pages: 1196 - 1201
      Abstract: Background: Patients who undergo internal fixation of ankle fractures commonly have postoperative imaging performed immediately after surgery. As these patients typically are typically immobilized, radiographs provide limited visualization. The purpose of this study was to evaluate the utility and quality of formal radiographs performed immediately following ankle fracture surgery. Methods: Ankle fractures undergoing open reduction and internal fixation at a single institution from January 1, 2011, to January 1, 2013, were reviewed. Intraoperative and formal postoperative radiographs were evaluated using defined parameters. The postoperative images were compared with the intraoperative fluoroscopic images in terms of quality. Postoperative complications were evaluated in terms of fracture displacement, hardware malpositioning, and need for return to the operating room. A total of 411 patients with 413 ankle fractures underwent surgical fixation, with 271 patients undergoing formal postoperative radiographs. Results: Twenty-eight patients (10.3%) had 3 good quality postoperative views of the ankle, with the lateral (35.2%) and mortise (41.3%) views least commonly performed with good technique. None of the patients without radiographs had a complication that could have been detected earlier using postoperative radiographs. No patients required return to the operating room based on immediate postoperative radiographs. Postoperative radiographs cost $191 per patient. Conclusion: The routine use of formal postoperative radiographs prior to discharge from the hospital did not provide additional value to the patient or orthopedic surgeon. The quality of these images was generally inferior to the quality of those obtained and saved intraoperatively due to malrotation and overlying cast material. To reduce cost and radiation exposure, formal postoperative radiographs should be obtained only in specific circumstances, such as increasing postoperative pain, marginal fixation, or instability. Level of Evidence: Level III, retrospective cohort study.
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715585591
      Issue No: Vol. 36, No. 10 (2015)
  • The Fate of the Fixed Syndesmosis Over Time
    • Authors: Gennis, E; Koenig, S, Rodericks, D, Otlans, P, Tornetta, P.
      Pages: 1202 - 1208
      Abstract: Background: A prior study demonstrated statistical widening of the syndesmosis within weeks of elective screw removal. However, no information is available as to the radiographic outcomes of screw retention. The aim of this study was to evaluate radiographic syndesmotic widening and talar shift over time in patients treated with syndesmotic screws and to compare screw removal with retention along with other potential risk factors that may have led to tibia-fibula diastasis after weightbearing. Methods: One hundred sixty-six skeletally mature patients with ankle fractures and concomitant syndesmotic injuries were treated with syndesmotic reduction and screw fixation. The syndesmosis was evaluated intraoperatively either by a stress test or direct visualization. If the syndesmosis was incompetent, it was reduced and stabilized with syndesmotic screws to maintain reduction. Anteroposterior, mortise, and lateral radiographs at presentation, postoperatively, and at follow-up after weightbearing were evaluated. We measured the medial clear space (MCS), tibia-fibula overlap (OL), and tibia-fibula clear space (CS). Screws that were retained were graded as loose/broken or intact. Results: The fibula shifted an insignificant amount on postoperative mortise radiographs after elective syndesmotic screw removal at 3 months or more after initial fixation, indicated by a slightly greater CS and lower OL. The MCS did not change from preoperative to postoperative screw removal. There was no change in the radiographic markers from the postoperative to final follow-up images in those whose screws became loose or broken. Likewise, there was no radiographic difference if screws remained intact versus those that were loose or broken. Conclusion: In contradistinction to prior work, we found that only very mild widening (0.5 mm) of the tibia-fibula space occurred after weightbearing following syndesmotic fixation. The removal of syndesmotic screws at 3 months resulted in a slightly lower OL (
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715588186
      Issue No: Vol. 36, No. 10 (2015)
  • Concomitant Ankle Injuries Associated With Tibial Shaft Fractures
    • Authors: Jung, K. J; Chung, C. Y, Park, M. S, Chung, M. K, Lee, D. Y, Koo, S, Lee, K. M.
      Pages: 1209 - 1214
      Abstract: Background: Ankle injuries associated with tibial shaft fractures can cause postoperative ankle pain and stiffness even when satisfactory bony union has been achieved. Although several previous studies have described these injuries, they have not been clearly defined or classified in terms of ankle injury type or need for surgical fixation. Methods: Seventy-one consecutive patients (mean ± SD age, 48.3 ± 16.7 years; 37 men and 34 women) with tibial shaft fractures who underwent computed tomography examination were included. Data were collected including age, sex, body mass index, fracture location of the tibia and fibula (in percentile of length), tibial fracture shape (spiral, oblique, transverse), presence and pattern of concomitant ankle injuries (on the distal tibial articular surface), and necessity for surgical fixation of ankle injuries. Factors associated with concomitant ankle injuries associated with tibial shaft fractures were analyzed by logistic regression analysis. Results: A total of 47 (64.7%) of the 71 tibial shaft fractures involved concomitant ankle injuries, including 8 cases of combined lateral malleolar fracture, posterior malleolar fracture, and anterior inferior tibiofibular ligament (AITFL) avulsion fracture; 9 cases of combined posterior malleolar fracture and AITFL avulsion fracture; 6 cases of combined lateral malleolar fracture and posterior malleolar fracture; 1 case of combined lateral malleolar fracture and AITFL avulsion fracture; 10 cases of posterior malleolar fracture; 7 cases of lateral malleolar fracture; 5 cases of AITFL avulsion fracture; and 1 unclassified fracture. Of these, 34 of the ankle injuries required surgical fixation. Spiral-type tibial shaft fracture was significantly associated with concomitant ankle injury (P = .001). Conclusions: Orthopaedic surgeons should be aware that tibial shaft fractures, especially spiral-type fractures, are frequently associated with ankle injuries, such as lateral malleolar fractures, posterior malleolar fractures, and AITFL avulsion fractures. A considerable portion of these cases may necessitate surgical fixation. We recommend all spiral-type tibial shaft fractures routinely undergo computed tomography examination. Level of Evidence: Level III, comparative series.
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715588381
      Issue No: Vol. 36, No. 10 (2015)
  • Double First Metatarsal and Akin Osteotomy for Severe Hallux Valgus
    • Authors: Al-Nammari, S. S; Christofi, T, Clark, C.
      Pages: 1215 - 1222
      Abstract: Background: The technique of double first metatarsal osteotomies was first developed in response to the high frequency of recurrence noted in the treatment of severe adolescent congruent hallux valgus deformities. The concept behind the use of this technique is that it allows the individual correction of each component of the deformity. We have modified the technique for use in adult hallux valgus where the majority of deformities are incongruent deformities and the distal chevron osteotomy is used primarily for its additional translational properties rather than purely to correct the distal metatarsal articular angle (DMAA). We report on a series of double first metatarsal osteotomies (basal opening wedge and distal chevron osteotomy) with Akin osteotomy in the treatment of moderate to severe adult hallux valgus deformity. Methods: All patients presenting to our institution with a hallux valgus deformity and treated with this procedure between 2008 and 2013 with a minimum of 1 year of follow-up were identified. Data were obtained through review of case notes, electronic charts, and digital imaging. A total of 50 feet in 48 patients underwent double first metatarsal osteotomy with Akin osteotomy. Three patients were excluded due to loss to follow-up, leaving 47 feet in 45 patients with a mean follow-up of 45 months (range, 14-60 months). Of these 43 (96%) were female and the mean age was 56 years (range, 35-70 years). Results: The mean preoperative hallux valgus angle (HVA), intermetatarsal angle (IMA), DMAA, sesamoid position, and lateral first metatarsotalar angle were 42 degrees (range, 32-52 degrees), 18 degrees (range, 6-26 degrees), 12 degrees (range, 4-26 degrees), stage 6 (range, 4-7), and 2 degrees of dorsiflexion (range, 20 degrees of dorsiflexion to 4 degrees of plantar flexion), respectively. The mean postoperative HVA, IMA, DMAA, sesamoid position, and lateral first metatarsotalar angle were 7 degrees (range, 2 to 24 degrees), 4 degrees (range, 4-14 degrees), 6 degrees (range, 10-22 degrees), stage 2 (range, 1-5) and 6 degrees of plantar flexion (range, 8 degrees of dorsiflexion to 18 degrees of plantar flexion), respectively. The osteotomies consolidated at a mean of 7 weeks (range, 5-9 weeks). There were no cases of delayed union or nonunion. Of the cohort, 45 (96%) stated that they were satisfied overall with the results of their surgery and would have it again. The mean postoperative summary index Manchester-Oxford Foot Questionnaire (MOXFQ) score was 12.9 (range, 0-60.9) out of 100 at a mean follow-up of 45 months (range, 14-60 months). For the minority of cases, 8 (17%), that had preoperative scoring, the summary index MOXFQ score was 73.7 (range, 29.7-100). Conclusions: The double first metatarsal osteotomy (basal opening wedge and distal chevron osteotomy) with Akin osteotomy provides powerful correction and facilitates correction of the individual components of the hallux valgus deformity. The individual osteotomies that make up this procedure are familiar to the majority of foot and ankle surgeons, thus limiting the associated learning curve. Level of Evidence: Level IV, retrospective case series.
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715589173
      Issue No: Vol. 36, No. 10 (2015)
  • Mid-term Results of Intramuscular Lengthening of Gastrocnemius and/or
           Soleus to Correct Equinus Deformity in Flatfoot
    • Authors: Rong, K; Ge, W.-t, Li, X.-c, Xu, X.-y.
      Pages: 1223 - 1228
      Abstract: Background: Intramuscular lengthening of the gastrocnemius and/or soleus (Baumann procedure) is widely used in patients who have cerebral palsy, with several advantages over other lengthening techniques. Tightness of the gastrocnemius or gastrocnemius-soleus complex has been confirmed to be related to flatfoot deformity. The purpose of this study was to evaluate the mid-term results of the Baumann procedure as a part of the treatment of flatfoot with equinus deformity. Methods: We reviewed 35 pediatric and adult patients (43 feet) with flatfoot who underwent the Baumann procedure for the concomitant equinus deformity. The mean duration of follow-up was 39.4 months. Preoperative and follow-up evaluations included the maximal angle of dorsiflexion of the ankle with the knee fully extended and with the knee flexed to 90 degrees, the American Orthopaedic Foot & Ankle Society ankle-hindfoot (AOFAS-AH) scores, and postoperative complications. Results: Preoperatively, the mean angle of passive ankle dorsiflexion with the knee extended was –4.7 ± 2.7 degrees and that with the knee flexed was 2.3 ± 2.5 degrees. At the final follow-up, both values improved significantly by a mean of 13.6 degrees (P < .001) and 9.7 degrees (P < .001), respectively. The average AOFAS-AH scores improved from 56.8 points preoperatively to 72.1 at the final follow-up. Recurrence of equinus was observed in 3 patients (4 feet). There were no cases of overcorrection, neurovascular injury, or healing problems. Conclusions: Our results indicate that the Baumann procedure can effectively and sequentially correct the tightness of the gastrocnemius or the gastrocnemius-soleus complex in patients with flatfoot deformity, without obvious postoperative complications. Level of Evidence: Level IV, retrospective case series.
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715588994
      Issue No: Vol. 36, No. 10 (2015)
  • Anatomic Feasibility Study of Posterior Arthroscopic Tibiotalar
    • Authors: Malekpour, L; Rahali, S, Duparc, F, Dujardin, F, Roussignol, X.
      Pages: 1229 - 1234
      Abstract: Background: Operative indications for an anterior arthroscopic tibiotalar arthrodesis are well defined. A posterior approach with the patient in a prone position may be indicated when the anterior approach is precluded by the soft tissue condition or for a 1-step procedure associated with posterior approach subtalar fusion. Methods: An anatomic study assessed the feasibility of posterior arthroscopic tibiotalar fusion and sought to determine arthroscopy entry points, mortise cartilage freshening quality, and the risk of osseous, tendinous, vascular, and neural complications. Twenty-two zones of the fibular tibiotalar mortise were mapped from 10 specimens. Medial and lateral para-Achilles arthroscopic portals were used with a 4 mm 30-degree arthroscope. Chondral resection was performed with a motorized burr, curette, and osteotome. Results: The entire plafond of the tibia could be debrided in all cases, whereas the talar dome was debrided in its entirety in 20% of cases; in 80%, only the posterior two-thirds could be treated with the anterior portion approaching the neck of the talus being poorly accessible. More than 50% of the area of the malleolar grooves was debrided. There was 1 medial malleolar fracture and 1 peroneal artery lesion. Conclusion: The technique was shown to be feasible if there was no frontal hindfoot deformity or tibiotalar equinus preventing satisfactory resection of the posterior and anterior talar cartilage. Clinical Relevance: This study demonstrated that a posterior approach arthroscopic ankle fusion would lead to adequate joint preparation. This procedure reduces the risk of nerve damage.
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715587232
      Issue No: Vol. 36, No. 10 (2015)
  • Biomechanical Comparison of External Fixation and Compression Screws for
           Transverse Tarsal Joint Arthrodesis
    • Authors: Latt, L. D; Glisson, R. R, Adams, S. B, Schuh, R, Narron, J. A, Easley, M. E.
      Pages: 1235 - 1242
      Abstract: Background: Transverse tarsal joint arthrodesis is commonly performed in the operative treatment of hindfoot arthritis and acquired flatfoot deformity. While fixation is typically achieved using screws, failure to obtain and maintain joint compression sometimes occurs, potentially leading to nonunion. External fixation is an alternate method of achieving arthrodesis site compression and has the advantage of allowing postoperative compression adjustment when necessary. However, its performance relative to standard screw fixation has not been quantified in this application. We hypothesized that external fixation could provide transverse tarsal joint compression exceeding that possible with screw fixation. Methods: Transverse tarsal joint fixation was performed sequentially, first with a circular external fixator and then with compression screws, on 9 fresh-frozen cadaveric legs. The external fixator was attached in abutting rings fixed to the tibia and the hindfoot and a third anterior ring parallel to the hindfoot ring using transverse wires and half-pins in the tibial diaphysis, calcaneus, and metatarsals. Screw fixation comprised two 4.3 mm headless compression screws traversing the talonavicular joint and 1 across the calcaneocuboid joint. Compressive forces generated during incremental fixator foot ring displacement to 20 mm and incremental screw tightening were measured using a custom-fabricated instrumented miniature external fixator spanning the transverse tarsal joint. Results: The maximum compressive force generated by the external fixator averaged 186% of that produced by the screws (range, 104%-391%). Fixator compression surpassed that obtainable with screws at 12 mm of ring displacement and decreased when the tibial ring was detached. No correlation was found between bone density and the compressive force achievable by either fusion method. Conclusion: The compression across the transverse tarsal joint that can be obtained with a circular external fixator including a tibial ring exceeds that which can be obtained with 3 headless compression screws. Screw and external fixator performance did not correlate with bone mineral density. This study supports the use of external fixation as an alternative method of generating compression to help stimulate fusion across the transverse tarsal joints. Clinical Relevance: The findings provide biomechanical evidence to support the use of external fixation as a viable option in transverse tarsal joint fusion cases in which screw fixation has failed or is anticipated to be inadequate due to suboptimal bone quality.
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715589083
      Issue No: Vol. 36, No. 10 (2015)
  • Tendoscopic Repair of the Superior Peroneal Retinaculum via 2 Portals for
           Peroneal Tendon Instability
    • Authors: Miyamoto, W; Takao, M, Miki, S, Giza, E.
      Pages: 1243 - 1250
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715604735
      Issue No: Vol. 36, No. 10 (2015)
  • Letter Regarding: Single-Photon-Emission Computed Tomography in Painful
           Total Ankle Replacements
    • Authors: Ellis; S. J.
      Pages: 1251 - 1251
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715604880
      Issue No: Vol. 36, No. 10 (2015)
  • Response to "Letter Regarding: Single-Photon-Emission Computed Tomography
           in Painful Total Ankle Replacements"
    • Authors: Mason, L. W; Molloy, A. P.
      Pages: 1252 - 1252
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715605085
      Issue No: Vol. 36, No. 10 (2015)
  • Letter Regarding: Comparison of Cannulated Screws Versus Compression
           Staples for Subtalar Arthrodesis Fixation
    • Authors: Mason, R; Baumhauer, J.
      Pages: 1253 - 1253
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715606890
      Issue No: Vol. 36, No. 10 (2015)
  • Response to "Letter Regarding: Comparison of Cannulated Screws Versus
           Compression Staples for Subtalar Arthrodesis Fixation"
    • Authors: Barg, A; Herrera-Perez, M.
      Pages: 1254 - 1254
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715606897
      Issue No: Vol. 36, No. 10 (2015)
  • Education Calendar
    • Pages: 1255 - 1255
      PubDate: 2015-10-01T15:32:44-07:00
      DOI: 10.1177/1071100715610763
      Issue No: Vol. 36, No. 10 (2015)
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