Fixation Article Of The Week

Nonunion Rate of First Metatarsal-Phalangeal Joint Arthrodesis for End-stage Hallux Rigidus with Crossed Titanium Flexible Intramedullary Nails and Dorsal Static Staple with Immediate Weight-bearing

noreply@blogger.com (Foot and Ankle Fixation) — Wed, 08 Feb 2012 16:41:00 +0000

Authors: Thomas Roukis DPM, Tristan Meusnier MD, Marc Augoyard MD

Journal: JFAS

Abstract: Myriad forms of fixation have been proposed for arthrodesis of the first metatarsal-phalangeal joint (MTPJ). Regardless of the fixation type, nonunion of the arthrodesis site has been purported to be a common complication. We performed a retrospective review of all patients undergoing arthrodesis of the first MTPJ for end-stage hallux rigidus with 2 crossed flexible titanium intramedullary nails and a dorsal static 10-mm titanium staple followed by immediate protected weight-bearing. The inclusion criteria were as follows: the exact internal fixation technique described was employed for end-stage hallux rigidus of the first MTPJ only; preoperative and at least 6 weeks of postoperative weight-bearing radiographs were available; weight-bearing was initiated on the operative foot immediately in a protective shoe; the patient was followed for at least 6 months postoperatively; any complication was documented; and bilateral surgery was not done in the same setting. A total of 42 female patients (51 feet) with a mean age ± SD of 69.4 ± 9.2 years met the inclusion criteria. Complications resulting from technical error during insertion of the crossed titanium flexible intramedullary nails occurred in 3 feet (5.9%), but none led to nonunion or revision surgery. One delayed union (2%) occurred but it ultimately united. The incidence of nonunion after arthrodesis of the first MTPJ consisting of 2 crossed flexible titanium intramedullary nails and a dorsal static 10-mm titanium staple for end-stage hallux rigidus in an exclusively female population was lower than the historic mean for most other fixation techniques. However, methodologically sound prospective cohort studies that focus on the use of isolated arthrodesis of the first MTPJ for end-stage hallux rigidus in both male and female patients are still needed, as are comparisons of the presented technique with other modern osteosynthesis techniques.

Keywords: degenerative joint disease, dorsal bunion, foot deformity, osteoarthritis, surgery

The Management of the Neglected Congenital Foot Deformity in the Older Child With the Taylor Spatial Frame

noreply@blogger.com (Foot and Ankle Fixation) — Mon, 30 Jan 2012 00:45:00 +0000

Authors: Atef Hassan, BS MBs MSc (Ortho) and Merv Letts, MD

Journal: Journal of Pediatric Orthopaedics

Abstract:

Background: Neglected or inadequately treated rigid congenitally deformed feet in older children are a nightmarish challenge for the child, the parents, and the orthopaedic surgeon. Because of the multiplicity of spatial deformities exhibited by these feet and legs, it was hypothesized that correction using the Taylor spatial frame (TSF) would decrease morbidity, facilitate correction, and minimize treatment time in children from remote regions with extremely rigid deformed feet.

Methods: Recent experience with the management of 11 such feet (Dimeglio type IV) in 9 children with an average age of 9.2 years using the TSF has been gratifying. Six children had associated leg length discrepancy, which was corrected by concomitant tibial lengthening. All feet underwent soft tissue releases, whereas forefoot and/or hindfoot osteotomies were performed in 7 feet.

Results: All children attained plantigrade, functional feet, and were fully ambulatory and capable of wearing normal footwear. Complications were minor consisting of pin tract infections, residual metatarsus varus in 3, and wound dehiscence in 1. There were no neurovascular events. This was attributed to the slower 3 plane correction using the TSF technique as well as the elimination of the need for plaster immobilization thus allowing direct monitoring of the foot and limb.

Conclusions: The rigid foot deformity in the older child can be safely and effectively corrected with the aid of the TSF, which facilitates a 3 plane correction and concomitant limb lengthening.

Keywords: Taylor spatial frame, neglected congenital deformities, limb length discrepancy

An Analysis of Outcomes after Use of the Maxwell-Brancheau Arthroereisis Implant

noreply@blogger.com (Foot and Ankle Fixation) — Mon, 16 Jan 2012 21:38:00 +0000

Authors: Steven Brancheau, DPM, Kelly Walker, DPM, and David Northcutt, DPM

Journal: JFAS

Abstract: The authors present a retrospective study of 35 consecutive patients (60 feet) treated with the Maxwell-Brancheau Arthroereisis (MBA) implant. The mean age of the cohort at the time of surgery was 14.3 (range 5 to 46) years, and 22 (62.86%) men and 13 (37.14%) women were included. Preoperative and postoperative anteroposterior and lateral foot radiographs were compared at a mean of 36 (range 18 to 48) months postoperatively, and the following mean changes were reported: talocalcaneal angle 24.15° ± 7.97° to 18.53° ± 8.23°, calcaneocuboid angle 18.67° ± 8.72° to 11.76° ± 8.49°, first to second intermetatarsal angle 9.42° ± 2.67° to 7.61° ± 2.69°, calcaneal inclination angle 11.93° ± 6° to 14.93° ± 5.85°, and talar declination angle 34.0° ± 8.59° to 28.02° ± 6.85°; all of these differences were statistically significant (p < .0001). A subgroup of 24 (68.57%) patients also answered a subjective questionnaire at a mean of 33 (range 12 to 55) months postoperatively. The presenting chief complaints were resolved in 23 patients (95.83%) of the subgroup, and 21 patients (87.5%) returned postoperatively to either the same or a greater activity level in sports. Twenty-three (95.83% of the subgroup) patients said they were 75% to 100% satisfied with their surgical outcome, and that they would recommend the surgery to a friend or family member with the same condition, whereas 1 (4.17%) claimed 0% satisfaction after placement of inappropriately sized implants (which were later replaced to the patient’s clinical satisfaction) in both feet

Keywords: calcaneus, flatfoot, pes valgoplanus, subtalar joint, surgery, talus

INBONE Total Ankle Replacement: Current Status

noreply@blogger.com (Foot and Ankle Fixation) — Thu, 15 Dec 2011 14:57:00 +0000

Authors: James K. DeOrio, MD

Journal: AAOS OrthoPortal

Abstract: The INBONE Total Ankle (Wright Medical Technology, Arlington, TN) replacement is a modular ankle replacement system consisting of an intramedullary stem whose pieces are inserted through the ankle and pushed up into the tibia to support the tibial tray of the device. The original talar component of the INBONE ankle is a saddle-shaped prosthesis that resurfaces only the top of the talus. A new talar design feature of the INBONE II ankle is a sulcus and two anterior prongs. Between the tibial and talar components of the INBONE, each consisting of a cobalt-chrome alloy, lies an ultra-high–molecular-weight polyethylene spacer locked into the tibial baseplate. In the INBONE II ankle, this polyethylene component is V shaped, to fit into the talar component of the prosthesis. This article describes the use of the INBONE ankle in total ankle arthroplasty and provides a detailed review of the surgical technique used for its achievement.

Keywords: Total ankle arthroplasty, ankle replacement system, INBONE

Rate of nonunion after First Metatarsal-Cuneiform Arthrodesis Using Joint Curettage and Two Crossed Compression Screw Fixation

noreply@blogger.com (Foot and Ankle Fixation) — Sun, 04 Dec 2011 14:29:00 +0000

Authors: Michael P. Donnenwerth, DPM; Sara L Borkosky, DPM; Bradley P. Abicht, DPM; Elizabeth J. Plovanich, DPM; Thomas S. Roukis, DPM, PhD, FACFAS.

Journal: JFAS

Abstract: First metatarsal-cuneiform joint arthrodesis is a commonly performed procedure to correct first ray pathology. The most widely accepted approach is curettage and 2 crossed compression screw fixation followed by a period of non–weight-bearing. Despite adequate joint preparation and stable internal fixation, nonunion has been cited as a known complication. This can lead to the need for revision surgery, which is undesirable and drives healthcare costs. To further investigate this topic, we conducted a systematic review to determine the rate of nonunion after the first metatarsal-cuneiform joint arthrodesis using curettage and 2 crossed compression screw fixation. Studies were eligible for inclusion only if they involved the following: arthrodesis of the first metatarsal-cuneiform joint with curettage and 2 crossed compression screw fixation, a minimum of 25 feet, with a mean follow-up of at least 6 months, and a period of postoperative non–weight-bearing. After considering all the potentially eligible references, 1 (1.8%) evidence-based medicine level I and 4 (7.3%) evidence-based medicine level IV studies met our inclusion criteria. A total of 537 patients (599 feet), 54 (10%) males and 483 (90%) females, with a weighted mean age of 49.4 years, were included. For those studies that specified the exact follow-up, the weighted mean was 30.9 months. A total of 30 nonunions (5%) were reported, with 17 (56.7%) symptomatic. The results of our systematic review revealed a relatively high rate of nonunion for first metatarsal-cuneiform joint arthrodesis with curettage and 2 crossed compression screw fixation, even when performed by experienced surgeons. Therefore, given the available data, additional prospective investigations are warranted, especially in the evaluation and comparison of fixation constructs and postoperative management.

Keywords: hallux valgus, Lapidus, metatarsus primus varus, tarsal-metatarsal joint, surgery

Three-wire Fixation Technique for Displaced Fifth Metatarsal Base Fractures

noreply@blogger.com (Foot and Ankle Fixation) — Mon, 21 Nov 2011 15:42:00 +0000

Authors: James L. Thomas & Barry C. Davis

Journal: Journal of Foot and Ankle Surgery

Abstract: Fractures of the tuberosity of the fifth metatarsal are the most common type of fifth metatarsal fractures. This particular fracture usually produces low morbidity and low rates of nonunion when treated nonoperatively. However, on occasion, significant displacement, comminution, or significant intra-articular involvement may warrant operative intervention. Multiple techniques have been described for the operative care of this fracture. We present a somewhat simplified fixation method for displaced fifth metatarsal fractures in a small set of patients who were all followed up to final healing of the fracture.

Keywords: bone, foot, injury, surgery, trauma

Mechanical Comparison of Two Types of Fixation for Ludloff Oblique First Metatarsal Osteotomy

noreply@blogger.com (Foot and Ankle Fixation) — Thu, 10 Nov 2011 14:52:00 +0000

Authors: Stavros P. Tsilikas, Emmanouil D. Stamatis, Stavros K. Kourkoulis, Athanasios S. Mitousoudis, Panayiotis E. Chatzistergos, Panayiotis J. Papagelopoulos

Journal: Journal of Foot and Ankle Surgery

Abstract: The Ludloff oblique metatarsal osteotomy is an effective method to correct hallux valgus deformity, although a number of problems have been associated with it, including inherent instability, delayed union, dorsal malunion, and fixation failure. The purpose of the present study was to compare the mechanical characteristics of fixation of the Ludloff osteotomy in 20 identical synthetic bone models, 10 fixated using 2 screws (group I) and 10 fixated using 2 screws augmented with a mini locking plate (group II). Each specimen was loaded to failure, and the mean average load to failure, stiffness, and absorbed energy to failure were compared using unpaired Student’s t test. The mean average stiffness of the Ludloff osteotomy fixed with 2 screws (group I) and with the supplementary mini locking plate (group II) was 172.7 ± 31.7 N/mm and 193.3 ± 39 N/mm, respectively (p = .21). The mean average load to failure for groups I and II was 278.4 ± 64.4 N and 356.2 ± 77.9 N, respectively (p = .025). The mean average energy absorbed before failure for groups I and II was 506.7 ± 206.4 Nmm and 769.8 ± 339.4 Nmm, respectively (p = .05). The use of a medially applied supplementary mini locking plate offers a simple and effective method to improve the mechanical stability of the Ludloff oblique osteotomy.

Keywords: bone, hallux valgus, interfragmental compression screw, locking plate, surgery

Advances in Intramedullary Nail Fixation in Foot and Ankle Surgery

noreply@blogger.com (Foot and Ankle Fixation) — Wed, 02 Nov 2011 19:21:00 +0000

Authors: Woods JB, and Burns PR

Journal: Clinics in Podiatric Medicine in Surgery

Abstract: Tibiotalocalcaneal arthrodesis for the treatment of complex foot and ankle deformities are extremely challenging cases. Technological advances in intramedullary nail fixation have improved the biomechanical properties of available fixation constructs in recent years. Nails designed specifically to accommodate hindfoot anatomy, advancement in the understanding of optimal screw orientation, fixed angle technology, the availability of spiral blade screws, and features designed to achieve compression across the arthrodesis site have provided the foot and ankle surgeon with a greater armamentarium for performing tibiotalocalneal arthrodesis. Although advances may help to improve clinical results, small sample sizes and the low-level evidence of study designs limit the evaluation of how these advances affect clinical outcomes.

Keywords: Tibiotalocalcaneal, Intramedullary nail, Foot, Ankle, Arthrodesis

Digital Arthrodesis: Current Fixation Techniques

noreply@blogger.com (Foot and Ankle Fixation) — Wed, 26 Oct 2011 13:18:00 +0000

Authors: Jared L. Moon, Carl A. Kihm, Daniel A. Perez, Leslie B. Dowling, David C. Alder

Journal: Clinics in Podiatric Medicine in Surgery

Abstract: Several hammertoe implant devices have recently been introduced in an attempt to provide optimal fixation for proximal interphalangeal joint arthrodesis. This article reviews these implants individually, and discusses their advantages and disadvantages. There is a lack of research with long-term follow-up available for these devices. Percutaneous Kirschner-wire fixation persists as a time-honored and effective method of fixation. The buried Kirschner-wire technique is also an effective, cost-conscious option, with many of the same advantages as newer implantable devices.

Keywords: Proximal interphalangeal joint arthrodesis, Hammertoe, Digital arthrodesis

Fractures of the Calcaneal Tuberosity Treated With Suture Fixation Through Bone Tunnels

noreply@blogger.com (Foot and Ankle Fixation) — Fri, 21 Oct 2011 14:44:00 +0000

Authors: Banerjee R, Chao J, Sadeghi C, Taylor R, Nickisch F.

Journal: Journal of Orthopaedic Trauma

Abstract: Fractures of the calcaneal tuberosity, although rare, present a challenge for the treating surgeon. The goal of treatment is restoration of function of the gastrocnemius–soleus complex and the Achilles tendon. These fractures often occur in diabetics and elderly osteoporotic patients and therefore fixation of the displaced fragment is difficult. Displaced fractures, if not recognized and promptly reduced, often result in secondary soft tissue compromise. Often, the fragment is a small shell of osteoporotic bone, which is less than optimal for bony fixation. We present our technique for surgical fixation of calcaneal tuberosity fractures using a suture placed through bone tunnels in the calcaneal body. This technique is used by itself for smaller fragments or supplemented with screw fixation for larger fragments.

Keywords: calcaneus fracture, calcaneal tuberosity, calcaneal avulsion

Evaluation of the syndesmotic-only fixation for Weber-C ankle fractures with syndesmotic injury

noreply@blogger.com (Foot and Ankle Fixation) — Thu, 13 Oct 2011 13:04:00 +0000

Authors: Mohammed R, Syed S, Metikala S, and Ali SA

Journal: Indian Journal of Orthopedics

Abstract: Background: With the length of the fibula restored and the syndesmosis reduced anatomically, internal fixation using a plating device may not be necessary for supra-syndesmotic fibular fractures combined with diastasis of inferior tibio-fibular joint. A retrospective observational study was performed in patients who had this injury pattern treated with syndesmosis-only fixation.

Materials and Methods: 12 patients who had Weber type-C injury pattern were treated with syndesmosis only fixation. The treatment plan was followed only if the fibular length could be restored and if the syndesmosis could be anatomically reduced. Through a percutaneous or mini-open reduction and clamp stabilization of the syndesmosis, all but one patient had a single tricortical screw fixation across the syndesmosis. Patients were kept non-weight-bearing for 6 weeks, followed by screw removal at an average of 8 weeks. Outcomes were assessed using an objective ankle scoring system (Olerud and Molander scale) and by radiographic assessment of the ankle mortise.

Results: At a mean follow-up of 13 months, the functional outcome score was 75. Excellent to good outcomes were noted in 83% of the patients. Ankle mortise was reduced in all cases, and all but one fibular fracture united without loss of fixation. Six patients had more than one malleolar injury, needing either screw or anchor fixations. One patient had late diastasis after removal of the syndesmotic screw and underwent revision surgery with bone grafting of the fibula. This was probably due to early screw removal, before union of the fibular fracture had occurred.

Conclusion: We recommend syndesmosis-only fixation as an effective treatment option for a combination of syndesmosis disruption and Weber type-C lateral malleolar fractures.

Keywords: Weber type-C ankle fractures, syndesmotic disruption, syndesmosis-only fixation, functional outcomes

Ankle Arthrodesis Utilizing a Single Lateral Exposure and Headless Screw Fixation

noreply@blogger.com (Foot and Ankle Fixation) — Wed, 05 Oct 2011 16:41:00 +0000

Authors: Taylor, BC

Journal: Techniques in Foot and Ankle Surgery

Abstract: Ankle arthrodesis is a well-accepted treatment method for patients with severe pain and dysfunction arising from degenerative changes of the ankle joint. Many different techniques have been described and can be appropriately utilized with the proper patient presentation. In this paper, we describe a technique of ankle arthrodesis performed utilizing a single lateral incision without fibular osteotomy and employing cannulated headless compression screw technology for fixation. When compared with traditional techniques, this approach has advantages of limited soft tissue dissection and periosteal stripping, possible incorporation of a previous surgical incision, rapid healing time and return of functionality, and elimination of hardware prominence.

Keywords: Ankle arthrodesis, lateral incision, headless screw

Fractures of the Proximal Fifth Metatarsal: Percutaneous Bicortical Fixation

noreply@blogger.com (Foot and Ankle Fixation) — Mon, 26 Sep 2011 14:00:00 +0000

Authors: Vivek Mahajan, MD, Hyun Wook Chung, MD, and Jin Soo Suh, MD

Journal: Clinics in Orthopedic Surgery

Abstract:

Background: Displaced intraarticular zone I and displaced zone II fractures of the proximal fifth metatarsal bone are frequently complicated by delayed nonunion due to a vascular watershed. Many complications have been reported with the commonly used intramedullary screw fixation for these fractures. The optimal surgical procedure for these fractures has not been determined. All these observations led us to evaluate the effectiveness of percutaneous bicortical screw fixation for treating these fractures.

Methods: Twenty-three fractures were operatively treated by bicortical screw fixation. All the fractures were evaluated both clinically and radiologically for the healing. All the patients were followed at 2 or 3 week intervals till fracture union. The patients were followed for an average of 22.5 months. Results: Twenty-three fractures healed uneventfully following bicortical fixation, with a mean healing time of 6.3 weeks (range, 4 to 10 weeks). The average American Orthopaedic Foot & Ankle Society (AOFAS) score was 94 (range, 90 to 99). All the patients reported no pain at rest or during athletic activity. We removed the implant in all cases at a mean of 23.2 weeks (range, 18 to 32 weeks). There was no refracture in any of our cases.

Conclusions: The current study shows the effectiveness of bicortical screw fixation for displaced intraarticular zone I fractures and displaced zone II fractures. We recommend it as one of the useful techniques for fixation of displaced zone I and II fractures.

Keywords: Fifth metatarsal, Proximal metatarsal fracture, Percutaneous fixation, Bicortical fixation.

Total Ankle Replacement with Use of a New Three-Component Implant

noreply@blogger.com (Foot and Ankle Fixation) — Tue, 20 Sep 2011 14:40:00 +0000

Authors: Pascal F. Rippstein, MD; Martin Huber, MD; J. Chris Coetzee, MD; Florian D. Naal, MD

Journal: JBJS TAR 3 Component System

Abstract:

Background: Total ankle arthroplasty has evolved over the past decade, and newer three-component implants have demonstrated favorable clinical results and improved survivorship. The present study analyzed the clinical and radiographic results of the first 240 total ankle arthroplasties performed by the authors with one of these new three-component prostheses. Methods: Two hundred and forty consecutive primary total ankle arthroplasties were performed in 233 patients (115 women and 118 men; mean age, 61.6 years) between November 2003 and October 2007 with the Mobility prosthesis. Intraoperative and postoperative complications, reoperations, and failures were recorded. The American Orthopaedic Foot & Ankle Society hindfoot score and a visual analog scale score assessment of pain were determined at each follow-up visit. Range of ankle motion was measured on functional radiographs, and the radiographs were studied to assess component positioning, radiolucencies, new bone formation, and periprosthetic bone cysts. Results: Two hundred and thirty-three of the arthroplasties were available for follow-up at least one year after surgery. The mean duration of follow-up was 32.8 ± 15.3 months. There were ten intraoperative complications (4.2%) and twenty postoperative complications (8.6%). A reoperation was necessary in eighteen ankles (7.7%). Five arthroplasties (2.1%) failed at a mean of twenty-seven months after surgery. The mean American Orthopaedic Foot & Ankle Society hindfoot score improved from 48.2 to 84.1 points (p < 0.001). The mean pain level decreased from 7.7 to 1.7 points (p < 0.001). The mean total range of ankle motion improved from 19.8° to 21.9° (p < 0.001). The tibial component had a mean of 2.1° of varus and a mean posterior slope of 6.0° relative to the tibial axis. The prevalence of nonprogressive radiolucency ranged from 1.8% to 37.3% in the ten zones surrounding the tibial component, and from 0 to 2.2% in the three zones surrounding the talar component. Conclusions: The short-term clinical and radiographic results after Mobility total ankle arthroplasty are encouraging and are at least comparable with those associated with other modern three-component implants. The minimum duration of follow-up of one year is short, and studies with longer follow-up are needed to confirm our findings.

Keywords:
ankle, ankle replacement arthroplasty, osteoarthritis of ankle, tibia, prosthesis implantation

Functional Outcomes after Fibula Locking Nail for Fragility Fractures of the Ankle

noreply@blogger.com (Foot and Ankle Fixation) — Thu, 08 Sep 2011 01:56:00 +0000

Authors: Aysha Rajeev, Shanaka Senevirathna, Sarkhell Radha, and N.S. Kashayap

Journal: JFAS Functional Outcomes after Fibula Locking Nail

Abstract: The aim of the present study was to assess the functional outcome of fragility fractures of the ankle treated with a fibular locking nail. A retrospective review of 24 patients with fragility fractures treated with a fibular locking nail from January 2005 to December 2007 was performed. The fibular nail used in our study was Biomet SST (stainless steel taper) small bone locking nail for the fibula. The Olerud and Molander scale was used to assess the functional outcome at the end of 1 year. The domains of the Olerud and Molander scale are pain, stiffness, swelling, stair climbing, running, jumping, squatting, support, and the activities of daily living. The patients were interviewed by telephone or the questionnaire was send by mail. Of the 24 patients, 2 were men and 22 were women. The left side was affected in 15 patients. The age group ranged from 71 to 91 years (average, 79). Of the fractures, 10 were lateral alveolus, 8 were bimalleolar, and 6 were trimalleolar fractures. All the patients were followed up at 6 weeks, 12 weeks, and after 6 months. The average period to fracture union was 8.7 weeks. No wound breakdown or any deep infections developed. The average Olerud and Molander scale score was 57 (range 30 to 65). The use of fibular locking nails to treat these difficult fracture are quite crucial to achieve early mobilization and also to maintain a good fracture position. In our study, the use of fibular nails was a very useful and successful method of treating fragility fractures with a very low risk of

complications. It also helps to restore function and results in patient satisfaction.

Keywords: Functional outcome, internal fixation, surgery, trauma

The Taylor Spatial Frame for Correction of Neglected Fracture Dislocation of the Ankle

noreply@blogger.com (Foot and Ankle Fixation) — Mon, 29 Aug 2011 13:25:00 +0000

Authors: Ravikiran Shenoy, George Kubicek, Michael Pearse

Journal: JFAS Taylor Spatial Frame

Treatment of neglected fracture dislocations of the ankle poses a surgical challenge. Extensive open reduction can frequently be contraindicated because of local skin conditions and contractures. The Taylor Spatial Frame™ (TSF) has been used to reduce and maintain reduction of complex fractures. Its use in fracture dislocation of the ankle joint has not been described. We describe a case where a TSF was used to reduce and treat a 6-week-old fracture dislocation of the ankle. The TSF is a versatile device, which has a role in the management of both acute and neglected fractures.

Keywords: Ankle fracture, dislocation, neglected fracture dislocation, Taylor Spatial Frame

Medial Malleolar Fractures: A Biomechanical Study of Fixation Techniques

noreply@blogger.com (Foot and Ankle Fixation) — Mon, 22 Aug 2011 13:00:00 +0000

Authors: T. Ty Fowler, MD; Kevin J. Pugh, MD; Alan S. Litsky, MD, ScD; Benjamin C. Taylor, MD; Bruce G. French, MD

Journal: ORTHOPEDICS August 2011;34(8):349

Fracture fixation of the medial malleolus in rotationally unstable ankle fractures typically results in healing with current fixation methods. However, when failure occurs, pullout of the screws from tension, compression, and rotational forces is predictable. We sought to biomechanically test a relatively new technique of bicortical screw fixation for medial malleoli fractures. Also, the AO group recommends tension-band fixation of small avulsion type fractures of the medial malleolus that are unacceptable for screw fixation. A well-documented complication of this technique is prominent symptomatic implants and secondary surgery for implant removal. Replacing stainless steel 18-gauge wire with FiberWire suture could theoretically decrease symptomatic implants. Therefore, a second goal was to biomechanically compare these 2 tension-band constructs.

Using a tibial Sawbones model, 2 bicortical screws were compared with 2 unicortical cancellous screws on a servohydraulic test frame in offset axial, transverse, and tension loading. Second, tension-band fixation using stainless steel wire was compared with FiberWire under tensile loads. Bicortical screw fixation was statistically the stiffest construct under tension loading conditions compared to unicortical screw fixation and tension-band techniques with FiberWire or stainless steel wire. In fact, unicortical screw fixation had only 10% of the stiffness as demonstrated in the bicortical technique. In a direct comparison, tension-band fixation using stainless steel wire was statistically stiffer than the FiberWire construct.

Key words: Medial Malleolar Fractures, Ankle Fracture Fixation Techniques

Distal Femoral Locking Plates for Tibiotalocalcaneal Fusions in the Charcot Ankle: A retrospective study

noreply@blogger.com (Foot and Ankle Fixation) — Mon, 15 Aug 2011 13:57:00 +0000

Authors: Sarah Shogren, DPM , Sara Zelinskas, DPM , Byron Hutchinson, DPM , Vineet Kamboj, DPM

Journal: The Foot and Ankle Online Journal 4 (8): 3

This paper presents a retrospective case series with chart and radiographic review of four patients with Charcot neuroarthropathy and associated ankle valgus. All four patients underwent tibiotalocalcaneal (TTC) arthrodesis using a distal femoral locking plate combined with external ring fixation for rigid axial compression. A 12 month follow-up was obtained. All four TTC arthrodeses were performed by the same surgeon (BH) including preoperative and postoperative evaluation and care. Outcomes were deemed successful with evidence of radiographic consolidation across the fusion sites. Outcomes were considered failures in the presence of non-union or amputation. Three patients had satisfactory outcomes with only minor complications. One patient had failure of the procedure with development of osteomyelitis and ultimately had a below knee amputation. Although this was a small review, on average, osseous consolidation was appreciated in 77 days for those patients that had successful outcomes. Larger retrospective or even prospective studies are needed to confirm the use of tibiotalocalcaneal arthrodesis using a distal femoral locking plate and external ring fixation in Charcot arthropathy. This small case series shows promise to the efficacy of distal femoral locking plates for tibiotalocalcaneal fusions.
Key words: Tibiotalocalcaneal fusions, Charcot Ankle, distal femoral locking plates, ankle valgus

Current Concepts Review: Results of Total Ankle Arthroplasty

noreply@blogger.com (Foot and Ankle Fixation) — Mon, 08 Aug 2011 15:23:00 +0000

Authors: Mark E. Easley, MD; Samuel B. Adams, MD; W. Chad Hembree, MD; James K. DeOrio, MD

Journal: J Bone Joint Surg Am. 2011; 93: 1455-1468

Most published reports related to total ankle arthroplasty have a fair to poor-quality level of evidence.

Comparative studies with a fair to good-quality level of evidence suggest that total ankle arthroplasty provides equal pain relief and possibly improved function compared with ankle arthrodesis.

On the basis of the current literature, survivorship of total ankle arthroplasty implants, when measured as the retention of metal components, ranges from 70% to 98% at three to six years and from 80% to 95% at eight to twelve years.

Several investigators have argued that, in the evolution of total ankle arthroplasty, some obligatory reoperation without removal of the metal implants is anticipated; examples of reoperation include relief of osseous or soft-tissue impingement, improvement of alignment or stability of the foot and ankle, bone-grafting for cystic lesions, and/or polyethylene exchange.

A successful return to low-impact, recreational sporting activities is possible after total ankle arthroplasty.

Key words: N/A

Locked Versus Nonlocked Plate Fixation For Hallux MTP Arthrodesis

noreply@blogger.com (Foot and Ankle Fixation) — Mon, 25 Jul 2011 15:48:00 +0000

Authors: Kenneth J. Hunt, MD; J. Kent Ellington, MD, MS; Robert B. Anderson, MD; Bruce E. Cohen, MD.

Foot & Ankle International: July 2011 (Vol.32 #7)

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.

Level of Evidence: III, Retrospective Comparative Study

Key Words: Hallux Arthrodesis; Hallux Valgus; Hallux Rigidus; Locked

Plate; Arthritis

Lapidus Arthrodesis with a Single Lag Screw and a Locking H-Plate

noreply@blogger.com (Foot and Ankle Fixation) — Mon, 18 Jul 2011 15:57:00 +0000

Authors: Christopher R.D. Menke, DPM; Michael C. McGlamry, DPM; Craig A. Camasta, DPM

The Journal of Foot and Ankle Surgery: Vol: 50, No. 4, 377-382. July 2011

The aim of this pilot study was to assess if using an interfragmental lag screw and a Darco® locking H-plate for the modified Lapidus arthrodesis in the treatment of hallux abducto valgus deformity (1) would allow for earlier weight bearing than previously described and (2) would indicate whether any changes would occur radiographically with the earlier weight bearing. Twenty-one metatarsocuneiform arthrodeses, in 18 patients, were retrospectively evaluated through chart review and postoperative radiographs. Original diagnoses included painful hallux abducto valgus and osteoarthritis of the first metatarsocuneiform joint. The mean age of the patients was 48 (range, 16 to 70) years. The mean follow-up duration was 38.5 (range, 29 to 60) months. The overall radiographic osseous union rate was 90.5% (19/21 feet), although there were 2 asymptomatic nonunions. There were no cases of fixation failure, and the surgical correction was preserved on follow-up radiographs. Overall, the mean time to full weight bearing was 4.7 (range, 3 to 7.5) weeks, and it was a mean of 8 (range, 7 to 10) weeks before the patient was back to wearing comfortable shoes. The authors concluded that metatarsocuneiform arthrodesis fixated with 1 interfragmentary lag screw and a Darco® locking H-plate provides sufficient stability to allow earlier weight bearing than has been previously described with other internal fixation constructs.

Level of Clinical Evidence: 4

Keywords: bunionectomy, fixation, foot, hallux abducto valgus, surgery

Posterior Approach Using Anterior Ankle Arthrodesis Locking Plate for Tibiotalocalcaneal Arthrodesis

noreply@blogger.com (Foot and Ankle Fixation) — Mon, 11 Jul 2011 15:02:00 +0000

Authors: Lawrence A. DiDomenico, DPM; Paul Sann, DPM

The Journal of Foot and Ankle Surgery: Online Only July 8th, 2011

Tibiotalocalcaneal arthrodesis is a successful treatment for patients with severe pain and functional disability in the ankle and subtalar joint. Patients with post-traumatic ankle and subtalar joint arthritis, and/or Charcot deformity, often present with compromised skin and soft tissue structures. In the present report, we describe a technique using an anterior ankle arthrodesis locking plate placed posteriorly to obtain hindfoot and ankle fusion. This technique, which uses the well vascularized, thick, posterior soft tissue envelope, provides very good exposure of the articular surfaces for resection and tibiotalocalcaneal fusion. The technique provides a valuable option for patients with compromised skin and soft tissue structures over aspects of the ankle that make other approaches risky and complicated.

Correction of Moderate to Severe Coronal Plane Deformity with the STAR Ankle Prosthesis

noreply@blogger.com (Foot and Ankle Fixation) — Tue, 05 Jul 2011 03:37:00 +0000

Authors: Rogor A. Mann, MD; Jeffrey A. Mann; Sudheer C. Reddy

Foot & Ankle International: July 2011 (Vol.32 #7)

Prior studies have demonstrated a correlation between the degree of

preoperative coronal plane deformity and failure following ankle

replacement. We reviewed all of our patients who underwent ankle

replacement utilizing the STAR prosthesis from 2000 to 2009 to evaluate

the outcome of those with moderate (10 to 19 degrees) and severe (20

degrees or greater) coronal plane deformity. Materials and Methods: Out

of 130 consecutive patients, 43 patients had at least 10 degrees of

preoperative coronal plane deformity. Twenty-five ankles had 10 to 19

degrees degrees of deformity and 18 ankles had 20 degrees

or greater deformity. Average age was 66 years. Average length of

followup was 41 (range, 12 to 98) months. Results: Average talar

preoperative deformity was 17.9 (range, 10 to 29) degrees, while

average initial talar postoperative deformity was 3.5 (range, 0 to 12)

degrees. Average final talar postoperative deformity was 4.7 (range, 0

to 14) degrees. Preoperative and final correction of deformity was

statistically significant (p <0.01), but there was no significant

difference between initial and final postoperative correction. Overall,

recurrence of the preoperative coronal plane deformity occurred in six

of 43 patients (14%). All three patients who had deformities over 25

degrees developed recurrences. Correction of the coronal plane

deformities was achieved by using intraoperative soft-tissue balancing,

including deltoid ligament release in 12 patients

and lateral ligament reconstruction in one patient. Deltoid ligament

release was found to be necessary for all patients with greater than 18

degrees of varus plane deformity. Conclusion: Correction of moderate to

severe coronal plane deformity with the STAR prosthesis was achievable

with only soft-tissue balancing procedures with predictable results

especially for deformities less than 25 degrees.

Level of Evidence: IV, Retrospective Case Series

Key Words: STAR; STAR Ankle; Scandinavian Total Ankle Replacement;

Ankle Replacement; Coronal Plane Deformity; Valgus; Varus; Deltoid

Release

Impaired Wound-Healing, Local Eczema, and Chronic Inflammation Following Titanium Osteosynthesis in a Nickel and Cobalt-Allergic Patient: A Case Report and Review of the Literature

noreply@blogger.com (Foot and Ankle Fixation) — Tue, 21 Jun 2011 03:44:00 +0000

Peter Thomas, MD¹; Manfred Thomas, MD²; Burkhard Summer, PhD¹; Karin Dietrich, MD¹; Melanie Zauzig³; Erwin Steinhauser, PhD³; Veit Krenn, MD⁴; Hans Arnholdt, MD⁵; Michael J. Flaig, MD¹

The Journal of Bone & Joint Surgery, Volume 93, Issue 11

Patients known to develop allergic reactions to nickel (Ni), cobalt (Co), or chromium (Cr) often develop eczema in association with items of daily use such as jewelry, earrings, or watchbands. The overall sensitization rates to these metals may range between 1.1% (chromium) and 13% (nickel) in the general population, with further differences based on age and sex¹. Chromium-cobalt alloys and stainless steel are widely used as orthopaedic implants and may release nickel, chromium, or cobalt into the surrounding tissues as a consequence of either wear or corrosion². Some patients with a metal allergy may develop dermatitis in association with orthopaedic implants, and the prevalence of dermal sensitivity in patients with a joint replacement, particularly a failed implant, is higher than that in the general population³. Metal sensitivity rates to nickel, cobalt, or chromium may be as high as 43% in orthopaedic patients with well-functioning implants and as high as 71% in patients with poorly functioning implants³. In contrast, because of their excellent biocompatibility, titanium (Ti)-based materials are not considered to provoke allergic reactions. Our patient developed eczema and impaired wound-healing following the fixation of an ankle fracture with titanium-based implants. Histological analysis of the tissue around the implant demonstrated inflammation primarily with lymphocytes, and a contact allergy to nickel and cobalt was found in the absence of titanium hyperreactivity, raising the question of a prior unknown nickel exposure as the source of the complications. The patient was informed that data concerning this case would be submitted for publication, and she consented.

Investigation performed at the Department of Dermatology and Allergology, Ludwig-Maximilians-University Munich, Munich; the Department of Precision- and Micro-Engineering/Engineering Physics, Munich University of Applied Sciences, Munich; the Department of Foot Surgery, Hessingpark-Clinic, Augsburg; and the Institute of Pathology, Augsburg, Germany

Total Ankle Replacement in the Varus Ankle

noreply@blogger.com (Foot and Ankle Fixation) — Tue, 14 Jun 2011 03:21:00 +0000

Authors: Shock, R., Christensen, J., Schuberth, J. (2011).

Reviewed by: James Johnston, DPM

The Journal of Foot and Ankle Surgery. Scientific Literature Review: 50, 5-10. June 2011

This is a retrospective study of patients with more than 5º of ankle varus arthrosis who underwent total ankle replacement before October 2007. Patient preoperative, immediate postoperative and most recent post operative weight bearing films were evaluated. The degree of varus deformity was determined by measurement of the long axis of the tibia to a perpendicular axis of the talar dome on AP and mortise views.

Results:
A total of 26 patients with preoperative varus ankle deformity of greater than 5 degrees were reviewed in the study. Patient ages ranged from 63.85 ± 9.33 years, with 7 females and 19 males. The average follow up was 16.69 ± 7.26 months. The average varus deformity was 18.3º ± 6.4º on the AP preoperative radiograph and 16.8º ±6.79º on the mortise projection. The immediate postoperative radiographs were measured and showed correction of 19º on the AP and 17º on mortise projections. All corrections where within 1º of postoperative films at follow up. There was a significant change in coronal plane correction of varus deformity on both AP and mortise views indicating either one can be used for preoperative planning. The sequence of corrective maneuvers for varus deformity was: Ancillary pedal procedures including but not limited to subtalar arthrodesis, ankle ligament reconstruction and talonavicular arthrodesis. A standard incisional approach was used followed by a medial deltoid sleeve release, lateral gutter resection, talar deformity reduction, tibial-talar preparation, component insertion and lateral ligament placation.

Conclusions:
At the time of review there has been no standard surgical approach to the varus ankle TAA in foot and ankle literature. This article demonstrates a stepwise approach to management of the rearfoot deformity and presents a convincing although limited case review for the indication of TAR in the varus ankle. The article points out that the varus ankle deformity frequently involves ligamentous imbalance with leads to a maladaptive joint. Previous literature has provided us with the suggestion that moderate to severe (10 º to 20 º) coronal plane deformity of the tibiotalar complex may be a contraindication to TAA. This article argues that with proper soft tissue balancing and the reestablishment of the plantigrade foot with a neutral ankle mortise, success can be found at least in the intermediate follow up.