Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Symposium: Recent Advances in Foot and Ankle Surgery 17 articles


Correction and Prevention of Deformity in Type II Tibialis Posterior Dysfunction

Stephen Parsons FRCS, Soulat Naim MCh, FRCS, Paula J. Richards BSc (Hons), MRCP, FRCR, Donald McBride FRCS, FRCS(Orth) Cobb described a method of reconstruction in Johnson and Strom Type II tibialis posterior dysfunction (TPD) using a split tibialis anterior musculotendinous graft. We assessed patient function and satisfaction after a modified Cobb reconstruction in a group of patients with a narrow spectrum of dysfunction, examined a modification of the Johnson and Strom classification to emphasize severity of deformity, and assessed the ability of the technique to prevent subsequent fixed deformity. We prospectively followed 32 patients managed by this technique and a translational os calcis osteotomy with early flexible deformity after failed conservative treatment. There were 28 women and four men with unilateral disease. The average followup was 5.1 years. Staging was confirmed clinically and with imaging. The modified surgery involved a bone tunnel in the navicular rather than the medial cuneiform with plaster for 8 weeks followed by orthotics and physiotherapy. All of the osteotomies healed and 29 of the 32 patients could perform a single heel rise test at 12 months. The mean postoperative American Orthopaedic Foot and Ankle Society hindfoot score was 89. One patient had a superficial wound infection and one a temporary dysesthesia of the medial plantar nerve; both resolved. The observations suggest the technique is a comparable method of treating early Johnson and Strom Type II TPD.,[object Object]

Endoscopic Gastrocnemius Recession for Treating Equinus in Pediatric Patients

John F. Grady DPM, Carolyn Kelly BS Gastrocnemius recessions have been performed as open or endoscopic procedures. Most of the literature describes the outcomes of these procedures in children with specific neurologic limitations. We report an alternative approach to endoscopic gastrocnemius recessions in neurologically healthy pediatric and adolescent patients whose gastrocnemius equinus could not be corrected nonoperatively. We prospectively followed 23 patients (16 boys, seven girls) who underwent 40 procedures for equinus deformity (n = 22) or osteoarthritis (n = 1). All patients had been directly referred for surgical treatment because all previous nonoperative treatments (stretching, night splints, orthotics, nonsteroidal anti-inflammatory drugs, and physical therapy) had failed. The indications for surgery were patients age 18 years or younger experiencing symptomatic equinus unresponsive to nonoperative care. Pre- and postoperative ankle dorsiflexion were measured. The minimum followup for study inclusion was 1 year (mean, 2.9 years; range, 2–5.1 years). For every patient, dorsiflexion range of motion improved (mean, 15°; standard deviation, 4°). No patient had diminished nerve sensation postoperatively. This technique can be used to correct gastrocnemius equinus in otherwise healthy children who have not benefited from prior nonsurgical treatment.,[object Object]

High Union Rates and Function Scores at Midterm Followup With Ankle Arthrodesis Using a Four Screw Technique

Hans Zwipp MD, PhD, Stefan Rammelt MD, PhD, Thomas Endres MD, Jan Heineck MD When evaluating the role of ankle arthrodesis in the treatment of severe ankle arthritis, postoperative infection, nonunion, and the development of arthritis at the adjacent joints are major issues when considering treatment alternatives. We evaluated the rate of complications, the functional outcome, and compensatory range of motion at the midtarsal joint at medium-term followup after ankle arthrodesis with four cancellous screws. We performed 94 ankle fusions in 92 patients; 12 patients were lost to followup and eight declined to participate, leaving 72 patients (76%) for evaluation. The minimum followup was 4.8 years (mean, 5.9; range, 4.8–7.8 years). No patient developed a deep infection; three patients developed postoperative hematoma which we operatively drained. Union occurred in 93 of the 94 patients (99%). The sagittal motion at the midtarsal joint averaged 24°. Secondary arthritis of the subtalar and talonavicular joints developed during the followup period in 17% and 11%, respectively. Progression of preexisting arthritis occurred in 13 of 43 patients (30%) at the subtalar joint and five of 26 patients (19%) at the talonavicular joint. None of these patients had fusion of an adjacent joint. The average American Orthopaedic Foot and Ankle Society score increased from 36 preoperatively to 85 at followup. Ankle arthrodesis with screws provides high rates of union, reliable pain relief, and favorable functional medium-term results.,[object Object]

Minimally Invasive Locked Plating of Distal Tibia Fractures is Safe and Effective

Mario Ronga MD, Umile Giuseppe Longo MD, Nicola Maffulli MD, PhD, MS, FRCS(Orth) Distal tibial fractures are difficult to manage. Limited soft tissue and poor vascularity impose limitations for traditional plating techniques that require large exposures. The nature of the limitations for traditional plating techniques is intrinsic to the large exposure required to approach distal tibia, a bone characterized by limited soft tissue coverage and poor vascularity. The locking plate (LP) is a new device for treatment of fractures. We assessed the bone union rate, deformity, leg-length discrepancy, ankle range of motion, return to preinjury activities, infection, and complication rate in 21 selected patients who underwent minimally invasive osteosynthesis of closed distal tibia fractures with an LP. According to the AO classification, there were 12 Type A, 5 Type B, and 4 Type C fractures. The minimum followup was 2 years (average, 2.8 years; range, 2–4 years). Two patients were lost to followup. Union was achieved in all but one patient by the 24th postoperative week. Four patients had angular deformity less than 7°. No patient had a leg-length discrepancy more than 1.1 cm. Five patients had ankle range of motion less than 20° compared with the contralateral side. Sixteen patients had not returned to their preinjury sporting or leisure activities. Three patients developed a delayed infection. We judge the LP a reasonable device for treating distal tibia fractures. The level of physical activities appears permanently reduced in most patients.,[object Object]

Double Posteromedial Portals for Posterior Ankle Arthroscopy in Supine Position

Francesco Allegra MD, Nicola Maffulli MD, MS, PhD, FRCS(Orth) Both posterior and anterior arthroscopy of the ankle may be indicated in the same patient. With the patient supine, it is possible to reach most intraarticular structures of the ankle through the standard anterior portals, but difficult to examine the posterior compartments and to perform hindfoot endoscopy. In most patients following the anterior procedure the patient is positioned prone to operate on the posterior compartment. We describe a two-portal posteromedial hindfoot procedure that allows the surgeon to reach both the posterior joint space and the extraarticular compartment of the hindfoot with the scope and instruments, regardless of diagnosis, with the patient supine. After arthroscopy on the anterior portion of the foot using standard anterior portals, the two posteromedial portals allow endoscopic inspection and management of abnormalities in this region without repositioning the patient and without any remarkable local complication.,[object Object]

Should One Consider Primary Surgical Reconstruction in Charcot Arthropathy of the Feet?

Thomas Mittlmeier MD, K. Klaue MD, Patrick Haar MD, Markus Beck MD Charcot neuroosteoarthropathy of the feet can induce severe instability and deformity with subsequent plantar ulceration leading to substantial disability or even amputation. Traditionally, nonoperative treatment is regarded as the primary option of treatment while surgery is restricted to treating complications or failure of nonoperative treatment. Failed nonoperative treatment essentially prolongs treatment period. We retrospectively reviewed 22 patients (26 feet) with midfoot (n = 9) or hindfoot (n = 17) neuropathy who underwent primary surgical reconstruction and reorientation arthrodesis due to manifest instability, nonplantigrade foot position, and deformity with overt (n = 8) or what we judged was impending ulceration (n = 9). The minimum followup was 0.5 years (mean, 2.7 years; range 0.5–7 years). All eight ulcers healed without recurrence of ulceration or manifestation of new ulcers during the followup period. We observed complications leading to further surgery in nine patients: five with perioperative hematoma and four with instability. AOFAS scores rose from a preoperative mean of 39 to 70 points (hindfoot cases) and from 51 points to 84 (midfoot cases). Early surgical reconstruction in high-risk patients can provide timely restoration of a plantigrade and stable foot and improved quality of life of the patient at complication rates comparable to those after secondary surgery following failed nonoperative treatment; however we emphasize we had no control group in this small case series for which we could compare nonoperative treatment.,[object Object]

The Scandinavian Total Ankle Replacement: Survivorship at 5 and 8 Years Comparable to Other Series

Alexia Karantana MD, Sally Hobson FRCS Orth, Sunil Dhar FRCS Ed Orth Ankle arthroplasty is increasingly used to treat advanced ankle arthritis. Earlier prostheses have given way to second-generation implants, on which we are accumulating medium-term data. The Scandinavian Total Ankle Replacement (STAR) is a three-component uncemented implant in wide use in Europe and the only mobile-bearing prosthesis with conditional approval in the United States. We retrospectively reviewed 45 patients (52 ankles) who had primary total ankle replacements using STAR prostheses, in order to assess survivorship and add to the pool of clinical data provided by independent practitioners required to establish this treatment as a viable alternative to arthrodesis. The minimum followup was 60 months (range, 60–110 months). Clinical outcome was determined using the AOFAS score. We determined the rate of radiographic loosening and recorded complications and the need for further surgery. Survival was 90% (95% CI 76.8 to 95.5) at 5 years and 84% (95% CI 68.9 to 92.2) at 8 years. Six of 52 ankles (11%) had component revision and two were converted to fusion. The mean postoperative AOFAS score was 78. The complication rate was 21%. Subsequent surgery, excluding component revision, was performed in nine of 52 (17%) ankles.,[object Object]

Percutaneous Treatment of Less Severe Intraarticular Calcaneal Fractures

Stefan Rammelt MD, PhD, Michael Amlang MD, Sven Barthel MD, Johann-Marian Gavlik MD, Hans Zwipp MD, PhD Percutaneous treatment of calcaneal fractures is intended to reduce soft tissue complications and postoperative stiffness of the subtalar joint. We assessed the complications, clinical hindfoot alignment, motion, functional outcome scores, and radiographic correction of percutaneous arthroscopically assisted reduction and screw fixation of selected, less severe fractures. We performed percutaneous reduction and screw fixation in 61 patients with Type II (Sanders et al.) calcaneal fractures. In 33 of 61 patients with displaced intraarticular fractures (types IIA and IIB), anatomic reduction of the subtalar joint was confirmed arthroscopically; these patients form the basis of this report. We observed no wound complications or infections. In two patients, one prominent screw was removed after 1 and 3 years, respectively. In one patient, arthroscopic arthrolysis was performed 1 year after the index procedure. Twenty-four of 33 patients (73%) were followed a minimum of 24 months (mean, 29 months; range, 24–67 months). The average American Orthopaedic Foot and Ankle Society ankle-hindfoot score at last followup was 92.1 (range, 80–100). Böhler’s angle and calcaneal width were reduced close to the values of the uninjured side. We believe percutaneous fixation is a reasonable alternative for moderately displaced Type II fractures provided adequate control over anatomic joint reduction with either subtalar arthroscopy or high-resolution (3-D) fluoroscopy.,[object Object]

Is Fibular Fracture Displacement Consistent with Tibiotalar Displacement?

Michel P. J. Bekerom MD, C. Niek Dijk MD, PhD We believed open reduction with internal fixation is required for supination-external rotation ankle fractures located at the level of the distal tibiofibular syndesmosis (Lauge-Hanssen SER II and Weber B) with 2 mm or more fibular fracture displacement. The rationale for surgery for these ankle fractures is based on the notion of elevated intraarticular contact pressures with lateral displacement. To diagnose these injuries, we presumed that in patients with a fibular fracture with at least 2 mm fracture displacement, the lateral malleolus and talus have moved at least 2 mm in a lateral direction without medial displacement of the proximal fibula. We reviewed 55 adult patients treated operatively for a supination-external rotation II ankle fracture (2 mm or more fibular fracture displacement) between 1990 and 1998. On standard radiographs, distance from the tibia to the proximal fibula, distance from the tibia to the distal fibula, and displacement at the level of the fibular fracture were measured. These distances were compared preoperatively and postoperatively. We concluded tibiotalar displacement cannot be reliably assessed at the level of the fracture. Based on this and other studies, we believe there is little evidence to perform open reduction and internal fixation of supination-external rotation II ankle fractures.,[object Object]

Favorable Outcome of Percutaneous Repair of Achilles Tendon Ruptures in the Elderly

Nicola Maffulli MD, MS, PhD, FRCS(Orth), Umile Giuseppe Longo MD, Mario Ronga MD, Anil Khanna MRCS, MS(Orth), Vincenzo Denaro MD Percutaneous repair of Achilles tendon (AT) ruptures reportedly reduces the risk of rerupture compared to nonoperative treatment and reduces the risk of wound infection compared to open surgery. We retrospectively reviewed the postoperative Achilles tendon total rupture score (ATRS), and the maximum calf circumference in 35 patients over 65 years of age who sustained an acute tear of the AT and underwent percutaneous repair of the AT. There were 26 men and nine women with a mean age at operation of 73.4 ± 8.7 years (range, 65–86 years). Of the 35 recruited patients, we report on 27 patients for whom we have a full data set. The minimum followup was 49 months (mean, 88 months; range, 49–110 months). The ATRS had a postoperative average rating of 69.4 ± 14 (range, 56–93). All patients were able to bear weight fully on the affected limb by the eighth postoperative week. The data suggest that percutaneous repair of the AT is a suitable option for patients older than 65, producing similar outcomes when compared to percutaneous repair in younger patients of previous reports.,[object Object]

Modified Rerouting Procedure for Failed Peroneal Tendon Dislocation Surgery

R. Gaulke MD, F. Hildebrand MD, M. Panzica, T. Hüfner MD, C. Krettek MD, FRACS

Recurrent dislocation of the peroneal tendons following operative treatment is relatively uncommon, but can be difficult to treat. We asked whether subligamental transposition of the peroneus brevis tendon, fibular grooving, and reattachment of the superior peroneal retinaculum for failed peroneal tendon dislocation surgery would achieve a stable fixation of the peroneal tendons and whether there would be restrictions of ROM or instability of the hindfoot. We reviewed six female patients (mean age, 24.5 years) with general laxity of joints preoperatively and at 6 weeks and 3, 6, and 12 months postoperatively. Within 1 year postoperatively no recurrence was found. In two ankles the extension was restricted 5° to 10°. In another pronation and supination was restricted 5° each. Stability of the ankle increased in four patients and stayed unchanged in two. AOFAS score increased from a mean value of 36 ± 20.6 preoperatively to 90 ± 7 postoperatively at 1 year. We conclude transposition of the peroneus brevis tendon is a reasonable treatment for failed peroneal tendon dislocation surgery.,[object Object]

Compartment Syndrome of the Lower Leg and Foot

Michael Frink MD, Frank Hildebrand MD, Christian Krettek MD, Jurgen Brand MD, Stefan Hankemeier MD Compartment syndrome of the lower leg or foot, a severe complication with a low incidence, is mostly caused by high-energy deceleration trauma. The diagnosis is based on clinical examination and intracompartmental pressure measurement. The most sensitive clinical symptom of compartment syndrome is severe pain. Clinical findings must be documented carefully. A fasciotomy should be performed when the difference between compartment pressure and diastolic blood pressure is less than 30 mm Hg or when clinical symptoms are obvious. Once the diagnosis is made, immediate fasciotomy of all compartments is required. Fasciotomy of the lower leg can be performed either by one lateral incision or by medial and lateral incisions. The compartment syndrome of the foot requires thorough examination of all compartments with special focus on the calcaneal compartment. Depending on the injury, clinical examination, and compartment pressure, fasciotomy is recommended via a dorsal and/or medial plantar approach. Surgical management does not eliminate the risk of developing nerve and muscle dysfunction. When left untreated, poor outcomes with contractures, toe deformities, paralysis, and sensory neuropathy can be expected. In severe cases, amputation may be necessary.,[object Object]

Syndesmotic Stabilization in Pronation External Rotation Ankle Fractures

Michel P. J. den Bekerom MD, Daniel Haverkamp MD, PhD, Gino M. M. J. Kerkhoffs MD, PhD, C. Niek Dijk MD, PhD Boden et al. suggested syndesmosis fixation was not necessary in distal pronation external rotation (PER) ankle fractures if rigid bimalleolar fracture fixation is achieved and was not necessary with deltoid ligament injury if the fibular fracture is no higher than 4.5 cm of the tibiotalar joint. We asked whether height of the fibular fracture with or without medial stability predicted syndesmotic instability as compared with intraoperative hook testing in these fractures. We reviewed 62 patients (35 male, 27 female) with a mean age of 45.6 years (range, 19–80 years). Using a bone hook applied to the distal fibula with lateral force to the distal fibula in the coronal plane, we fluoroscopically assessed the degree of syndesmosis diastasis in all patients. The mean height of the fibular fracture in patients with a positive hook test was higher than in patients with a negative hook test (54.2 mm; standard deviation [SD], 29.3 versus 34.8 mm; SD, 21.4, respectively). The height of the fibular fracture showed a positive predictive value of 0.93 and a negative predictive value of 0.53 in predicting syndesmotic instability; specificity of the criteria of Boden et al. was high (0.96). However, sensitivity was low (0.39) using the hook test as the gold standard. The criteria of Boden et al. may be helpful in planning, but may have some limitations as a predictor of syndesmotic instability in distal PER ankle fractures.,[object Object]

Lasso Stitch with Peroneal Retinaculoplasty for Repair of Fractured Os Peroneum: A Report of Two Cases

Vincent James Sammarco MD, Daniel J. Cuttica DO, G. James Sammarco MD Fracture of the os peroneus with retraction of the peroneus longus tendon can lead to weakness, instability, and progressive foot deformity. Treatment recommendations vary and include simple immobilization, repair of the fractured ossicle, excision of part or all of the fractured ossicle with repair of the tendon and tenodesis with the peroneus brevis tendon. We present two patients treated with excision of the proximal fragment and repair of the tendon to the distal fragment with relief of pain and restoration of function. The distal fragment was captured with a looped suture which allowed avoidance of a plantar exposure while still achieving an adequate repair. We also describe a technique for retinaculoplasty of the inferior peroneal retinaculum which we believe important to prevent postoperative adhesions to the tendon.,[object Object]