Anish R. Kadakia

Radiographic Results After Percutaneous Distal Metatarsal Osteotomy for Correction of Hallux Valgus Deformity

Background: The goal of the study was to evaluate the short-term radiographic results and complications of a percutaneous distal metatarsal osteotomy for hallux valgus. Methods: From June, 2005, until October, 2005, a percutaneous distal first metatarsal osteotomy was performed in 13 consecutive patients. All patients had mild to moderate hallux valgus deformities preoperatively. The mean postoperative followup was 130 (range 50 to 207) days. The radiographs were reviewed for hallux valgus angle, 1-2 intermetatarsal angle, nonunion, malunion, and osteonecrosis. Results: The mean 2 weeks postoperative hallux valgus angle demonstrated a statistically significant (p < 0.0001) improvement from 25 (16 to 33) degrees preoperatively to 5 (−1 to 12) degrees postoperatively. Nine patients (69%) demonstrated dorsally angulated alignment of the first metatarsal at the first postoperative examination averaging 10.8 (6 to 15) degrees that increased to 15.9 (10 to 22) degrees at final followup. One patient developed cystic changes within the metatarsal head consistent with osteonecrosis. One patient developed a nonunion with no evidence of radiographic healing at most recent followup of 180 days. Five patients (38%) had recurrent hallux valgus defined as a final angle of greater than 15 degrees. Conclusions: Percutaneous distal metatarsal osteotomy for hallux valgus is associated with an unacceptable rate of complications, specifically, osteonecrosis, nonunion, malunion, and recurrence. The intraoperative correction was routinely lost after removal of the intramedullary Kirschner wire, leading to a high rate of recurrence of hallux valgus deformity as well as dorsal elevation of the capital fragment.

Fresh Osteochondral Total Ankle Allograft Transplantation for the Treatment of Ankle Arthritis

Background: Fresh osteochondral total ankle allograft transplantation has been reported in the literature with survival rates between 50% and 92% at 1- to 12-years followup. The goal of this study was to present the results of total ankle allografts from another institution. Materials and Methods: Twenty-nine patients underwent osteochondral total ankle transplant at our institution between July 2003 and July 2005. The mean patient age was 41 years old and the mean followup duration was 2 years. Results: At followup, 14 of the 29 transplants had been revised to a repeat ankle transplant, prosthetic total ankle arthroplasty, or bone block arthrodesis. In addition, 6 of the remaining 15 transplants were deemed to be radiographic failures due to allograft fracture, allograft collapse, or progressive loss of joint space. The remaining 9 allografts (31%) were considered successes. In comparing the success versus the failure group, patients who were older, who had a lower body-mass index, and who had minimal preoperative angular deformity did significantly better. Conclusion: This is the largest series of osteochondral total ankle allograft transplants reported in the literature to date. There is an extremely high rate of failure associated with this procedure, and we currently consider it only rarely in patients who are too young for ankle replacement, have excellent range of motion, low body mass index, normal radiographic alignment, and who refuse arthrodesis.

Posterior malleolus fracture.

&NA; Posterior malleolus fractures are a common component of ankle fractures. The morphology is variable; these fractures range from small posterolateral avulsion injuries to large displaced fracture fragments. The integrity of the posterior malleolus and its ligamentous attachment is important for tibiotalar load transfer, posterior talar stability, and rotatory ankle stability. Fixation of posterior malleolus fractures in the setting of rotational ankle injuries has certain benefits, such as restoring articular congruity and rotatory ankle stability, as well as preventing posterior talar translation, but current indications are unclear. Fragment size as a percentage of the anteroposterior dimension of the articular surface is often cited as an indication for fixation, although several factors may contribute to the decision, such as articular impaction, comminution, and syndesmotic stability. Outcome studies show that, in patients with ankle fractures, the presence of a posterior malleolus fracture negatively affects prognosis. Notable variability is evident in surgeon practice.

An Anatomical Way of Treating Ankle Syndesmotic Injuries

Treatment of tibiofibular syndesmotic ankle injury remains controversial in regard to the best method, although surgeons agree that the goal of treatment is reduction and operative stabilization. Ideally, the implant should stabilize the syndesmosis and allow physiologic micromotion and early mobilization, and conventional screws are limited in this regard. We reviewed use of the Ankle TightRope(®) fixation device for repair of syndesmotic injuries. From April to September 2006, 16 patients with evidence of syndesmotic injury were treated by means of ankle fracture open reduction with internal fixation, combined with use of the Ankle TightRope(®) device for repair of the syndesmosis. The mean age of the 16 patients was 36.6 ± 16.71 (range 15 to 69) years; they were followed up for at least 2 years. Mean follow-up duration was 26 ± 3.94 (range 24 to 38) months. The mean American Orthopaedic Foot and Ankle Society score at 2-year follow-up was 86.88 ± 11.49 (range 48 to 100). The mean time to full weight-bearing was 4.5 ± 0.87 weeks. Two (12.5%) patients had postoperative superficial wound infections, each of which was treated with oral antibiotics. One (6.25%) patient had the TightRope(®) removed because of irritation from the knot. There was no failure of syndesmotic fixation, despite early weight-bearing in the postoperative phase. The results of this case series indicate that tibiofibular syndesmosis repair with the Ankle TightRope(®) yields satisfactory results.

Radiographic evaluation of the normal distal tibiofibular syndesmosis.

Background: Diagnosis of syndesmotic injuries is primarily based upon the assessment of ankle radiographs. The purpose of our study was to redefine the radiographic relationships of the ankle syndesmosis based on a large series of normal ankle radiographs in living subjects. Methods: The study involved 392 patients (218 females, 174 males) with ankle radiographs without known clinical or radiographic evidence of abnormality. Eighty-three of the 392 patients had also had normal contralateral radiographs. Tibiofibular overlap and tibiofibular clear space were measured on anteroposterior (AP) and mortise radiographs. The radiographic measurements were used to calculate means, standard deviations, and intra- and interob-server reliabilities, and compare genders and side-to-side radiographs. Results: The mean overlap was 8.3 mm on the AP and 3.5 mm on the mortise while the mean clear space was 4.6 mm on the AP and 4.3 mm on the mortise view. The least amount of overlap on the AP view was 1.8 mm. On the mortise view, there was a subset of patients that had a complete lack of overlap (less than 0 mm) with the greatest gap noted to be 1.9 mm. The greatest clear space on AP was 8 mm and on the mortise was 7.6 mm. Mortise clear space was the most accurate measure when obtaining contralateral radiographs, with a mean side-to-side difference of 0.7 ± 0.7 mm. Conclusion: Lack of overlap on the mortise view can represent a normal variant, which has not been definitively reported in prior investigations. Clinical Relevance: Our data form the basis for revised radiographic criteria to evaluate the distal tibiofibular syndesmosis which may influence clinical management of these patients.

Posterior pilon fractures: a retrospective case series and proposed classification system.

Background: Posterior malleolus fractures occur in 7% to 44% of ankle fractures and are associated with worse clinical outcomes. Fractures that involve the posteromedial plafond extending to the medial malleolus have been described previously in small case series. Failure to identify this fracture pattern has led to poor clinical outcomes and persistent talar subluxation. The purpose of this study was to report our outcomes following fixation of this posterior pilon fracture and to describe a novel classification system to help guide operative planning and fixation. Methods: Eleven patients were identified following fixation of a posterior pilon fracture over a 4-year span; 7 returned at minimum 1-year follow-up to complete a physical examination, radiographs, and RAND-36 (health-related quality of life score developed at RAND [Research and Development Corporation] as part of the Medical Outcomes Study) and American Orthopaedic Foot & Ankle Society (AOFAS) ankle/hindfoot questionnaires. Patient records were reviewed to evaluate for secondary complications or operative procedures. Results: Our mean postoperative AOFAS ankle/hindfoot score was 82. Anatomical reduction of the plafond was noted radiographically in 7 of 11 patients, with the remainder demonstrating less than 2 mm of articular incongruity. Five of 7 patients demonstrated ankle and hindfoot range of motion within 5 degrees of the uninvolved extremity. Four complications required operative intervention; 2 patients reported continued pain secondary to development of CRPS. Conclusion: The posterior pilon fracture is a challenging fracture pattern to treat, and it has unique characteristics that require careful attention to operative technique. Our results following fixation of this fracture pattern are comparable with results in the literature. In addition, a novel classification scheme is described to guide recognition and treatment of this fracture pattern. Level of Evidence: Level IV, retrospective case series.

Surgical Management of Hallux Rigidus: Cheilectomy and Osteotomy (Phalanx and Metatarsal)

Cheilectomy has long been the standard treatment in the orthopedic community for mild to moderate cases of hallux rigidus, with established long-term excellent results. Osteotomies of the proximal phalanx and first metatarsal have been described mainly in the podiatric literature; they have shown good outcomes in small patient groups with short-term follow-up. Proper patient selection is critical to obtaining favorable outcomes with any of the joint-sparing procedures. Patients with severe arthritic changes and pain in the midrange arc of motion have poorer outcomes with these procedures and are better served with joint-destructive procedures, such as arthroplasty or arthrodesis.

Variability in radiographic medial clear space measurement of the normal weight-bearing ankle.

Background: Medial clear space (MCS) width on mortise radiographs of the ankle is commonly used by clinicians for determining the competence of the deltoid ligament in the Weber B supination–external rotation ankle fracture. Significant variability exists in the current literature regarding methods of obtaining this measure and definition of a normal measure in comparison with a pathologic state. Methods: Seventy-three paired bilateral ankle mortise radiographs that were without ankle pathology were retrospectively reviewed. MCS width at two separate locations (oblique and perpendicular) and superior clear space (SCS) were measured on digital radiographs. A Students t test was used to compare mean values. Results: Mean values (± SD) were 3.2 (± 0.7) mm for MCS oblique, 2.6 (± 0.7) mm for MCS perpendicular, and 3.3 (± 0.6) mm for SCS. A significant difference (p < .001) existed for all three measures between males and females. MCS oblique was statistically different than MCS perpendicular (p < .001) for all patients and for males and females independently. The mean difference between paired bilateral radiographs was 0.3 (± 0.2) mm for MCS oblique, 0.6 (± 0.6) mm for MCS perpendicular, and 0.2 (± 0.2) mm for SCS. Conclusions: MCS width has variability based on the location chosen for measurement and gender. Contralateral radiographic comparison of MCS should be routinely used to identify pathologic widening versus normal anatomic variation. Clinical Relevance: Use of single threshold values for MCS width as an operative indicator may produce a false-positive diagnosis of deltoid incompetence in Weber B supination–external rotation ankle fractures and possibly lead to unnecessary surgery.

Hindfoot arthrodesis for the adult acquired flat foot

This article reviews hindfoot arthrodesis for the adult acquired flat foot. Discussion of triple arthrodesis, triple arthrodesis with the addition of a lateral column lengthening procedure, triple arthrodesis with the addition of a plantar flexion first metatarsoncuneiform arthrodesis, and an isolated subtalar arthrodesis are discussed. The indications, surgical techniques, outcome studies, and complications are addressed.

Radiographic Study of the Fifth Metatarsal for Optimal Intramedullary Screw Fixation of Jones Fracture

Background: Jones fractures occur in the relatively avascular metadiaphyseal junction of the fifth metatarsal (MT), which predisposes these fractures to delayed union and nonunion. Operative treatment with intramedullary (IM) screw fixation is recommended in certain cases. Incorrect screw selection can lead to refractures, nonunion, and cortical blowout fractures. A better understanding of the anatomy of the fifth MT could aid in preoperative planning, guide screw size selection, and minimize complications. Methods: We retrospectively identified foot computed tomographic (CT) scans of 119 patients that met inclusion criteria. Using interactive 3-dimensional (3-D) models, the following measurements were calculated: MT length, “straight segment length” (distance from the base of the MT to the shaft curvature), and canal diameter. Results: The diaphysis had a lateroplantar curvature where the medullary canal began to taper. The average straight segment length was 52 mm, and corresponded to 68% of the overall length of the MT from its proximal end. The medullary canal cross-section was elliptical rather than circular, with widest width in the sagittal plane and narrowest in coronal plane. The average coronal canal diameter at the isthmus was 5.0 mm. A coronal diameter greater than 4.5 mm at the isthmus was present in 81% of males and 74% of females. Conclusion: To our knowledge, this is the first anatomic description of the fifth metatarsal based on 3-D imaging. Excessive screw length could be avoided by keeping screw length less than 68% of the length of the fifth metatarsal. A greater than 4.5 mm diameter screw might be needed to provide adequate fixation for most study patients since the isthmus of the medullary canal for most were greater than 4.5 mm. Clinical Relevance: Our results provide an improved understanding of the fifth metatarsal anatomy to guide screw diameter and length selection to maximize screw fixation and minimize complications.