Introduction

AlloStem/Cellular Bone Allograft and autologous bone graft are accepted methods for managing hindfoot degenerative arthritis. The purpose was to evaluate outcomes of AlloStem and autograft in subtalar arthrodesis and compare overall fusion rates.

Background

Revision total ankle arthroplasty (TAA) can be extremely challenging due to bone loss and deformity. We present the results examining the preliminary indications and short term outcomes for the use of the Salto XT revision prosthesis.

Background

Subtalar nonunion has a detrimental effect on patients' function, and pose a significant challenge for surgeons particularly in the setting of higher risk factors.

Müller Weiss disease (MWD) is characterized by lateral navicular necrosis which is associated with a varus alignment of the subtalar joint, varying degrees of arthritis of the talonavicular-cuneiform joints and a paradoxical flatfoot deformity in advanced cases. Although arthrodesis of the hindfoot is commonly used, we present the results of a previously unreported method of treatment using a calcaneus osteotomy incorporating a wedge and lateral translation.

Fourteen patients with MWD who were treated with a calcaneus osteotomy were retrospectively reviewed. There were seven females and seven males with an average age of 56 years (range 33–79), and included one grade 5, five grade 4, four grade 3 and four grade 2 patients. Patients had been symptomatic for an average of eleven years (range 1–14), and all underwent initial conservative treatment with an orthotic support that posted the heel into valgus. The primary indication for surgery was a limited but positive response to the use of the orthotic support, and a desire to avoid an arthrodesis of the hindfoot.

Background

There have been multiple techniques described to determine hindfoot alignment radiographically. The 2-dimensional nature of radiographs fails to take into account the contribution of the remainder of the foot to overall alignment. A new radiographic technique has been published in which the hindfoot alignment is calculated using the Ground Reaction Force Calcanea Offset. This technique accounts for the individual forefoot contribution to alignment, but is still limited by it´s 2-dimensional nature. The purpose of this study was to compare the hindfoot moment arm (HMA) described by Saltzman and the hindfoot alignment angle (HAA) described by Williamson, with a technique determining the ground reaction force calcaneal offset (GRF-CT) using 3-dimensional weight bearing CT Scans.

Introduction

Metatarsus adductus (MA) increases the risk of recurrence following surgery for hallux valgus (HV). The goal of this study was to analyze patients with severe MA and identify clinical/surgical factors that are associated with a lower rate of recurrent deformity.

Introduction:

The purpose of this study was to elucidate the specific radiographic effects that the Cotton osteotomy confers when used in combination with other reconstructive procedures in the management of the flexible flat foot deformity.

Background

The Weil osteotomy is successful in the management of metatarsalgia and toe deformity. The aim is to achieve controlled shortening whilst avoiding plantarflexion. Recognised complications of the Weil osteotomy include a ‘floating toe’ in up to 20% or more of cases.

Tibiotalocalcaneal fusion is generally reserved for complex cases such as severe deformity or bone loss, infection, Charcot and revision procedures. Subsequently published series have been small and there are no studies comparing plate fixation and intramedullary nailing. We present the outcomes in the largest series to date and have also compared the union rate and complication rate between blade plate fixation (36) and intramedullary nailing (46). Both groups were well matched for patient and disease factors.

There was a non-statistically significant trend towards better outcomes with nails. Further analysis was conducted comparing the two fixation methods by the indication for surgery, there were no statistically significant differences, the reasons for these findings are discussed.

We analyzed the radiographic results of patients treated surgically for flatfoot deformity and who underwent medial cuneiform opening wedge osteotomy as part of the operative procedure. The aim of this study was to confirm the utility of the cuneiform osteotomy as part of the correction of hindfoot and ankle deformity. All patients requiring operative management of flatfoot deformity between January 2002 and December 2007 were prospectively entered in a database. We selected all patients who underwent medial cuneiform opening wedge osteotomy. We measured standardized and validated radiographic parameters on pre and post-operative weight bearing radiographs of the foot. All radiographs were assessed using the digital imaging software package (Siemens). The following measurements were used: lateral talus-1st metatarsal angle; medial cuneiform to floor distance (mm), talar declination angle, calcaneal-talar angle, calcaneal pitch angle, 1st metatarsal declination angle, talonavicular coverage angle, and anteroposterior talus-1st metatarsal angle. Other variables including concomitant surgical procedures, healing of the osteotomy, malunion, and adjacent joint arthritis were also noted. There were 86 patients with a mean age of 36 years (range 9–80). 15 patients had bilateral surgery. The aetiology of the deformity was flexible flat-foot in 48, rupture of the posterior tibial tendon in 41, rigid flatfoot deformity with a fixed forefoot supination deformity in 7, and fixed forefoot varus with metatarsus elevatus in 5. In addition to an opening wedge medial cuneiform osteotomy, a lateral column lengthening calcaneus osteotomy was performed in 80, a gastrocnemius recession in 76, a supramalleolar osteotomy in 2, a triple arthrodesis in 4, a subtalar arthroerisis in 13, excision of an accessory navicular in 6, a tendon transfer in 15 and medial-slide calcaneal osteotomy in 8 patients. The mean lateral talus-1st metatarsal angle improved from 23° to 1°; the mean medial cuneiform to floor distance improved from 20mm to 34mm; the mean talar declination angle improved from 39° to 27°; the mean calcaneal-talar angle improved from 64° to 55°; the calcaneal pitch angle improved from 14° to 23°; the mean 1st metatarsal declination angle improved from 17° to 26°; the mean talonavicular coverage angle improved from 45° to 18°; and the mean anteroposterior talus-1st metatarsal angle improved from 19° to 0° Radiographical analysis confirms that the medial cuneiform opening wedge osteotomy is a reliable and valuable surgical tool in the correction of the forefoot which is associated with flatfoot deformity and that arthrodesis of the 1st metatarsocuneiform joint may not be required to obtain correction of the elevated 1st metatarsal.

Ankle arthrodesis is a common operation with published fusion rates ranging from 62–100%. The literature documents the difficulties of obtaining arthrodesis in certain patients for example with neuroarthropathy, but the risk of non union related to deformity, bone quality, bone defects and systemic disease has not previously been reported.

Between 2002 and 2006 we performed an ankle arthrodesis in 154 patients, and analyzed these patients retrospectively to delineate categories of risk factors for achieving arthrodesis. From this analysis we devised a preoperative radiographic scoring system to grade complexity of pre-operative ankle arthrodesis. The scoring system is based upon 5 categories; size and plane of deformity, presence and size of bone defects, presence and area of avascular necrosis, site of previous fracture in post-traumatic arthritis and predisposing condition causing the arthritis. Each category has potential scores of 1–5, apart from the latter which is scored up to 6, with higher scores being more severe. The grade of complexity is derived from a cumulative score from all 5 categories.

Statistical analysis revealed good intra and inter- observer correlation. Multivariate regression analysis demonstrated that this scoring system correlates with the techniques used for arthrodesis as well as outcome. This study demonstrated that if the method of arthrodesis is altered according to the relative risk of non –union then there is no significant difference in outcome between patients of high and low risk for non-union

We present a new scoring system for severity of pre-operative condition in ankle arthrodesis patients and introduce an algorithm for surgical correction based upon this pre-operative scoring system. The surgical techniques for the arthrodesis are presented, ranging from simple screw fixation to more complex bone grafting techniques, bone stimulation and alternative methods of fixation.

We present our experience with a medial approach for triple arthrodesis for correction of severe rigid hindfoot deformity in patients who were at risk for wound complications with a standard lateral approach.

Between 1995 and 2002, we treated 17 patients with a rigid hindfoot valgus deformity, and for whom a triple arthrodesis was planned, using a single medial incision. The indication for surgery was pain refractory to shoe wear, orthotic and brace modifications. The severity of the hindfoot deformity itself was not sufficient an indication for this procedure, since during the same time period, 157 triple arthrodesis procedures were performed using a two incision technique, many of which were associated with severe hindfoot varus or valgus deformities. The medial incision was indicated specifically for patients who were at risk for wound complications following correction of the hindfoot valgus deformity due to stretching of the lateral skin.

There were 15 patients with rheumatoid arthritis (RA), and two patients who had deformity of the hind-foot following a crush injury associated with scarring of the lateral skin over the sinus tarsi. In addition to standard weight bearing radiographs of the foot and ankle, non-invasive vascular studies were performed in 5/17 patients pre-operatively who on clinical examination were considered to have peripheral vascular disease.

Immunosuppressant medication(s) were not discontinued prior to surgery for the patients with RA, and were renewed once wound healing occurred. The surgery was performed in a standard manner for each patient, with an extensile medial incision, the use of a laminar spreader to facilitate exposure and joint debridement, and removal of appropriate bone wedges to improve correction. Cannulated partially threaded 5.0 mm (for the talonavicular and calcaneocuboid joints) and 6.5 mm (for the subtalar joint) screws were used in each patient.

All 17 patients were examined a mean of 4.5 years following surgery (range 2.5–8), and the examination focused on the success of arthrodesis, the presence of ankle arthritis, as well as hindfoot deformity. Other outcome parameters were not specifically examined since these patients had multiple additional lower limb deformities, as well as arthritides of the foot and ankle unrelated to the performance of the triple arthrodesis. The correction obtained was compared with preoperative radiographs.

There were no wound healing complications in any patient. Arthrodesis was obtained in 16/17 patients. In one patient with RA, a non-union of the calcaneocuboid joint was noted radiographically, but had been present for 6 years, and was asymptomatic. There was no loss of correction, however hindfoot valgus was present in three patients, caused by arthritis of the ankle associated with valgus tibiotalar deformity. Two additional patients had since undergone a total ankle replacement for correction of arthritis not associated with deformity, and one had undergone an ankle arthrodesis 2 years following the triple arthrodesis for correction of severe arthritis as well as tibiotalar deformity. On the anteroposterior foot radiograph, the talus-first metatarsal angle improved from a mean of 26 degrees (range 15–45), to a mean of 5 degrees (range 0–15). The talocalcaneal angle was not measured, since reproducible preoperative measurements could not be obtained. The axial talocalcaneal angle was not measured.

The medial approach to triple arthrodesis is a reliable procedure, and can be used with a predictable outcome in patients who are at risk for wound healing complications for correction of hindfoot valgus deformity.

Aims: To evaluate the outcome of our consecutive series of patients who underwent revision surgery due to unresolved or recurrent symptoms after an initial procedure or procedures for interdigital neuroma excision. Methods: In a six year period 49 patients underwent revision neuroma surgery utilizing a dorsal approach. Sixty interspaces were re-explored. In addition, ten patients underwent primary neuroma resection from an adjacent interspace, while 19 patients underwent concomitant forefoot surgery. Results: The average duration of postoperative follow-up was 39.7 months. Fifteen patients (30.7%) were completely satis-þed, thirteen (26.5%) satisþed with minor reservations, ten (20.4%) satisþed with major reservations and eleven (22.4%) dissatisþed with the postoperative outcome. The exploration of two adjacent interspaces, the intraopera-tive þndings, the concomitant forefoot surgery and the previous attempts at re-exploration had an inßuence on the þnal outcome. Seven patients (14.3%) had no footwear restrictions, thirteen patients (26.5%) had mild, twenty-one (42.9%) had moderate and eight (16.3%) severe footwear restrictions. Nineteen patients (38.8%) had no activity restrictions, twenty-two (44.9%) had mild, eight (16.3%) moderate and none reported severe restrictions interfering with daily activities. Conclusions: Persistent or recurrent symptoms after nerve transection present a challenging problem for both the surgeon and the patient. Thorough preoperative discussion must be undertaken with the patient, providing the average rates of failure and the increased likelihood of footwear and activity restrictions.

Aims: The purposes of the current retrospective study were to evaluate the outcome of a consecutive series of supramalleolar osteotomies and to identify the inßu-ence of the technique (opening versus closing wedge) on the outcome and the union rate. Methods: In a þve year period, we performed a supramalleolar osteotomy for the correction of distal tibial mechanical malalign-ment of at least 10¡, with concomitant pain and with or without radiographic evidence of arthritic changes, or as an alternative to other common procedures, for the treatment of a small group of patients with degenerative changes of the ankle joint. Results: There were 14 patients (15 feet) with an average follow up of 31.1 months. All osteotomies healed at an average time of 13.6 weeks. The average AOFAS score improved from 53.8 to 87 points, the average Takakura score from 56.7 to 82 and the average pain score from 13.5 to 31.4. In the presence of deformity the average values of TAS and TLS angles were signiþcantly improved. The radiographic degenerative changes in the ankle joint showed no evidence of progression. The choice of technique did not inßuence the clinical- radiographic outcome and the healing time of the osteotomy. Conclusions: Supramalleolar osteotomy is a useful procedure to: a. reconstruct the normal mechanical environment in malunion preventing or decelerating any long term deleterious effects and improving pain and function levels, and b. to shift and redistribute loads in the ankle joint in an effort to protect the articular cartilage from further degenerative process.

Aims: The purposes of the current retrospective study were to evaluate the outcome of a consecutive series of supramalleolar osteotomies and to identify the influence of the technique (opening versus closing wedge) on the outcome and the union rate.

Methods: In a five year period, we performed a supra-malleolar osteotomy for the correction of distal tibial mechanical malalignment of at least 10°, with concomitant pain and with or without radiographic evidence of arthritic changes, or as an alternative to other common procedures, for the treatment of a small group of patients with degenerative changes of the ankle joint.

Results: There were 14 patients (15 feet) with an average follow up of 31.1 months. All osteotomies healed at an average time of 13.6 weeks. The average AOFAS score improved from 53.8 to 87 points, the average Takakura score from 56.7 to 82 and the average pain score from 13.5 to 31.4. In the presence of deformity the average values of TAS and TLS angles were significantly improved. The radiographic degenerative changes in the ankle joint showed no evidence of progression. The choice of technique did not influence the clinical- radiographic outcome and the healing time of the osteotomy.

Conclusions: Supramalleolar osteotomy is a useful procedure to: a. reconstruct the normal mechanical environment in malunion preventing or decelerating any long term deleterious effects and improving pain and function levels, and b. to shift and redistribute loads in the ankle joint in an effort to protect the articular cartilage from further degenerative process.

Aims: To evaluate the outcome of our consecutive series of patients who underwent revision surgery due to unresolved or recurrent symptoms after an initial procedure or procedures for interdigital neuroma excision.

Methods: In a six year period 49 patients underwent revision neuroma surgery utilizing a dorsal approach. Sixty interspaces were re-explored. In addition, ten patients underwent primary neuroma resection from an adjacent interspace, while 19 patients underwent concomitant forefoot surgery.

Results: The average duration of postoperative follow-up was 39.7 months. Fifteen patients (30.7%) were completely satisfied, thirteen (26.5%) satisfied with minor reservations, ten (20.4%) satisfied with major reservations and eleven (22.4%) dissatisfied with the postoperative outcome. The exploration of two adjacent interspaces, the intraoperative findings, the concomitant forefoot surgery and the previous attempts at re-exploration had an influence on the final outcome. Seven patients (14.3%) had no footwear restrictions, thirteen patients (26.5%) had mild, twenty-one (42.9%) had moderate and eight (16.3%) severe footwear restrictions. Nineteen patients (38.8%) had no activity restrictions, twenty-two (44.9%) had mild, eight (16.3%) moderate and none reported severe restrictions interfering with daily activities.

Conclusions: Persistent or recurrent symptoms after nerve transection present a challenging problem for both the surgeon and the patient. Thorough preoperative discussion must be undertaken with the patient, providing the average rates of failure and the increased likelihood of footwear and activity restrictions.

Insertional Achilles tendonitis is an inflammatory disorder affecting mainly active young patients. The etiology is multifactorial and include the combination of anatomical and biomechanical characteristics. One fifth of the tendon injuries in athletes are insertional complaints which includes bursitis and insertion tendinitis.The complex of the insertion of the Achilles tendon includes three main components of fibrocartilage sesamoid, periosteum and enthesis. A conservative regime is recommended as the first line of treatment. In case of failure a surgical decompression of the posterior margin of the calcaneum is indicated.

Nine cadaveric legs were used for the experiment. The leg was mounted on an MTS machine and was axially loaded 360 N. The foot was attached to a plate which enabled dorsal and plantar flexion. The Achilles was sutured twice in an Ethibond No. 5 using the Krakow technique in order to anchor the tendon to an actuator. A thin pressure sensor plate (Teckscan) was inserted into the retrocalcaneal bursa to measure the force, pressure and contact area of the Achilles to the calcaneus in various positions of the foot. The conditions included 90 degrees of the foot, 15 and 30 degrees of dorsiflexion while the tension that was applied on the Achilles was 0, 200 N and 300 N. After resection of the posterior surface of the calcaneus in a 20 degrees inclination.

The mean peak force, pressure and area did not change in Achilles tensioning while the foot was in 90 degrees and were close to zero. In 15 degrees of dorsiflexion there was increase in the mean peak force, pressure and area when the Achilles was tensed to 200 and 300 Newton. Larger increase in these parameters was achieved by further dorsiflexion of the foot to 30 degrees.

After resection of the posterior margin of the calcaneus in an angle of 20 degrees the mean peak force, pressure and area dropped close to zero and remained almost unchanged during the various conditions of the experiment.

Dorsiflexion and tension of the Achilles tendon increases the mean peak force, pressure and area in the Achilles retrocalcaneal bursa. These data may explain the mechanism for insertional Achilles tendinosis. Resection of the posterior surface of the calcaneus in 20 degrees efficiently decompresses the retrocalcaneal bursa in various angles of the foot and in various tensions of the Achilles.