Anne Johnson

Nonoperative Treatment of an Os Peroneum Fracture in a High-level Athlete: A Case Report

BackgroundThe os peroneum is a sesamoid bone in the peroneus longus tendon. Fractures of the os peroneum are rare. Some authors recommend surgery for active patients.Case DescriptionA 41-year-old male professional tennis coach sustained a minimally displaced fracture of the os peroneum. He was treated with restricted weightbearing for 2xa0weeks, followed by physical therapy and gradual return to activities. He returned to tennis 8xa0weeks after injury. Followup 7xa0years after the injury showed he had full strength, full motion, and a radiographically healed os peroneum. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score was 100 and Ankle Activity Score and Tegner Activity Level Scale were unchanged from those before injury.Literature ReviewFracture of the os peroneum is a rare injury and treatment recommendations are based largely on very small series and case reports. Proposed treatment strategies for fracture of the os peroneum include nonoperative treatment, fixation of the fracture, excision of the bone with direct repair of the tendon, and tenodesis of the peroneus longus to the peroneus brevis.Purposes and Clinical RelevanceAlthough some surgeons suggest fracture of the os peroneum should be treated operatively in active patients, this case shows nonoperative treatment allowed pain-free return to activities in a high-level athlete with a minimally-displaced fracture.

Hallux saltans due to stenosing tenosynovitis of flexor hallucis longus: dynamic sonography and arthroscopic findings

Triggering of the toes is rare, with isolated cases reported in the literature involving predominantly the flexor hallucis longus (FHL) tendon, a condition known as “hallux saltans” (HS). We report the dynamic sonographic findings of a 42-year-old female with a 2-month history of ankle pain and triggering of right hallux, consistent with HS. Sonography demonstrated tenosynovitis and focal thickening of FHL at the level of hindfoot, with a fibrous band adjacent to the tendon. Dynamic ultrasound showed triggering and snapping of FHL tendon during hallux flexion and extension, respectively. We present comprehensive documentation of this rare entity, including sonographic still images and cine clips, as well as correlation with arthroscopic surgical findings.

The arthroscopic syndesmotic assessment tool can differentiate between stable and unstable ankle syndesmoses

Purpose Patients with stable isolated injuries of the ankle syndesmosis can be treated conservatively, while unstable injuries require surgical stabilisation. Although evaluating syndesmotic injuries using ankle arthroscopy is becoming more popular, differentiating between stable and unstable syndesmoses remains a topic of on-going debate in the current literature. The purpose of this study was to quantify the degree of displacement of the ankle syndesmosis using arthroscopic measurements. The hypothesis was that ankle arthroscopy by measuring multiplanar fibular motion can determine syndesmotic instability. Methods Arthroscopic assessment of the ankle syndesmosis was performed on 22 fresh above knee cadaveric specimens, first with all syndesmotic and ankle ligaments intact and subsequently with sequential sectioning of the anterior inferior tibiofibular ligament, the interosseous ligament, the posterior inferior tibiofibular ligament, and deltoid ligaments. In all scenarios, four loading conditions were considered under 100N of direct force: (1) unstressed, (2) a lateral hook test, (3) anterior to posterior (AP) translation test, and (4) posterior to anterior (PA) translation test. Anterior and posterior coronal plane tibiofibular translation, as well as AP and PA sagittal plane translation, were arthroscopically measured. Results As additional ligaments of the syndesmosis were transected, all arthroscopic multiplanar translation measurements increased (p values ranging from p u2009<u20090.001 to p u2009=u20090.007). The following equation of multiplanar fibular motion relative to the tibia measured in millimeters: 0.76*AP sagittal translationu2009+u20090.82*PA sagittal translationu2009+u20091.17*anterior third coronal plane translation—0.20*posterior third coronal plane translation, referred to as the Arthroscopic Syndesmotic Assessment tool, was generated from our data. According to our results, an Arthroscopic Syndesmotic Assessment value equal or greater than 3.1xa0mm indicated an unstable syndesmosis. Conclusions This tool provides a more reliable opportunity in determining the presence of syndesmotic instability and can help providers decide whether syndesmosis injuries should be treated conservatively or operatively stabilized. The long-term usefulness of the tool will rest on whether an unstable syndesmosis correlates with acute or chronic clinical symptoms.

How Will the Foot and Ankle Orthopedic Community Respond to the Growing Opioid Epidemic

In the midst of the current opioid crisis, it has become critically important to properly manage opioid-prescribing patterns for the treatment of postoperative pain. There is currently a scarcity of literature specifying prescription and consumption patterns following orthopedic surgery and specifically foot and ankle surgery. Clinical guidelines for postoperative pain management are deficient.

Opioid Prescribing Patterns of the American Orthopaedic Foot & Ankle Society

Category: Other Introduction/Purpose: Amid the current opioid epidemic in the United States, surgeons are forced to more carefully manage postoperative pain prescriptions. Despite the enthusiastic engagement of physicians, politicians and the general public, however, clear guidelines for opioid prescribing postoperatively still do not exist, including after foot and ankle surgery. Given the ablity to improve patient outcomes by decreasing treatment variability in other realms of medicine, this study sought to quantify the postoperative opioid prescribing regimens of American foot and ankle surgeons as an initial step towards understanding prescription patterns and establishing a baseline regimen from which future guidelines may stem. Methods: A total of 1235 active and candidate members of the American Orthopaedic Foot & Ankle Society (AOFAS) from the United States and Canada were invited to fill out a postoperative pain management survey using a Research Electronic Data Capture (REDCap) web-based application. Surgeons were asked to report on their pain prescription regimens, including type and number of pills, after nine common foot and ankle procedures rated as minor, moderate, or major in severity. The presence of a regional block anesthesia was also recorded. Opioid prescriptions were then converted to the equivalent of 5 mg oxycodone pills for standardization and inter-prescriber comparison. Results: Two hundred twenty-four (18%) surgeons completed the survey. Because of highly skewed data results are reported as medians and the range. Postoperative opioid prescriptions, given in oxycodone 5 mg pill equivalents, were as follows: 39 (8-133) pills for minor procedure, 45 (10-180) pills for a moderate soft tissue procedure, 53 (16-186) pills for a moderate bony procedure, and 60 (20-200) pills for a major bony procedure. Conclusion: Wide variation between surgeons was noted in postoperative pain management. Median prescription opioid doses vary from 39 to 60 oxycodone pills depending on procedure type. It is likely that the amount of opioids prescribed is excessive for adequate pain management, especially for smaller procedures. We propose a post-operative pain regimen that limits the number of pills prescribed based on studies from other surgical specialties. Future studies are necessary to assess the efficacy of current postoperative pain management practices and to guide improved pain management that limits the use of opioids where possible.

Isolated Intermetatarsal Ligament Release as Primary Surgical Management for Morton’s Neuroma: the Carpal Tunnel of the Foot?

Category: Midfoot/Forefoot Introduction/Purpose: While the precise pathoetiology of Morton’s neuroma remains unclear, nerve inflammation as a result of chronic entrapment from the overlying intermetatarsal ligament (IML) may play a role. Traditional surgical management involved common digital nerve transection with neuroma excision, but this procedure risks unpredictable formation of a stump neuroma and potential worsening of symptoms. Accordingly, the senior author has over the past six years espoused isolated IML release and common digital nerve decompression in lieu of nerve transection or neuroma excision as an alternative treatment strategy. We hypothesized that IML release offers effective pain relief and high patient satisfaction level as a surgical treatment for recalcitrant Morton’s neuroma without the risk of stump neuroma formation or symptom exacerbation. Methods: Medical records for all consecutive patients treated surgically with isolated single interspace IML release for symptomatic and recalcitrant Morton’s neuroma over a four year period at a large academic medical center were examined. Any adult patient with clinically diagnosed Morton’s neuroma who had failed at least three months of conservative treatment and who then underwent single-webspace IML decompression were included. Any patient who had less than three months postoperative follow up, had undergone revisional neuroma surgery, or had undergone additional procedures at the time of the IML release were excluded. Overall patient satisfaction as well as pre- and post-operative Visual Analog Pain Scale (VAS) assessments were recorded for all patients. Results: Eleven patients underwent isolated, single interspace IML decompression for Morton’s neuroma over this time frame. One of these patients had a neuroma localized to the second web space and 10 were localized to the third web space. Average follow-up was 10.8± 9 (3-32) months (Table 1). VAS pain scores averaged 6.4 ± 1.9 (4-9) preoperatively and decreased to an average of 1.5 ± 1.6 (0-5) at final follow up (P = 0.003). All patients reported significant pain improvement and an overall satisfaction with the procedure (would undergo it again). No patients returned to the operating room, there were no postoperative infection nor worsening of pain, and no other complications were reported. Conclusion: Isolated single interspace IML release of chronically symptomatic Morton’s neuroma shows promising short-term results regarding pain relief and overall patient satisfaction, with few complications and no demonstrated risk of recurrent neuroma formation, permanent numbness, or postoperative symptom exacerbation. The authors’ collective experience with this approach has been positive enough over the past six years to result in the entire abandonment of the practice of neuroma excision in this patient population.

Effect of Fixation Type and Bone Graft on Tarsometatarsal Fusion

Background: End-stage tarsometatarsal (TMT) arthritis is commonly treated with arthrodesis of involved joints. Fixation hardware can consist of varying combinations of screws, plates, and staples with or without supplemental bone graft. There are limited data to demonstrate either superiority of a given fixation method or the impact of bone graft on fusion rates. The purpose of this study, therefore, was to determine whether nonunion rates after TMT arthrodesis were influenced by either the use of screw vs plate fixation or the addition of bone graft vs no bone graft. Methods: All patients older than 18 years undergoing arthrodesis for TMT arthritis between July 1991 and July 2016 were identified retrospectively. Exclusion criteria included less than 12 months follow-up, prior midfoot surgery, any added procedure beyond TMT arthrodesis using plates or screws, and acute foot trauma. All patients with radiographic or clinical nonunion, including those requiring revision surgery, were identified. Demographic data and associated risk factors were recorded via chart and radiographic image review. Eighty-eight patients (88 feet, mean follow-up: 75.1 ± 51.4; range, 12-179), with a total of 189 joints and who met enrollment criteria were treated by 9 different surgeons with arthrodesis. Results: The overall nonunion rate was 11.4%. Significant independent risk factors associated with nonunion were (1) arthrodesis using plate fixation with all screws through the plate (odds ratio [OR], 6.2; 95% confidence interval [CI], 1.8-21.3; P = .004), (2) smoking during the perioperative period (OR, 7.9; 95% CI, 2.1-30.2; P = .002), and (3) postoperative nonanatomic alignment (OR, 11.2; 95% CI, 2.1-60.8; P = .005). Bone graft utilization was found to significantly lower the rate of nonunion (OR, 0.2; 95% CI, 0.1-0.6; P = .006). Conclusion: Isolated plate fixation, smoking, and postoperative nonanatomic alignment appear to significantly increase the rate of nonunion among patients undergoing TMT arthrodesis for midfoot arthritis. Concomitant use of autogenous bone graft significantly decreased this risk. Level of Evidence: Level III, retrospective comparative study.

Reoperation Rate Differences Between Open Reduction Internal Fixation and Primary Arthrodesis of Lisfranc Injuries

Background: Controversy persists as to whether Lisfranc injuries are best treated with open reduction internal fixation (ORIF) versus primary arthrodesis (PA). Reoperation rates certainly influence this debate, but prior studies are often confounded by inclusion of hardware removal as a complication rather than as a planned, staged procedure inherent to ORIF. The primary aim of this study was to evaluate whether reoperation rates, excluding planned hardware removal, differ between ORIF and PA. A secondary aim was to evaluate patient risk factors associated with reoperation after operative treatment of Lisfranc injuries. Methods: Between July 1991 and July 2016, adult patients who sustained closed, isolated Lisfranc injuries with or without fractures and who underwent ORIF or PA with a minimum follow-up of 12 months were analyzed. Reoperation rates for reasons other than planned hardware removal were examined, as were patient risk factors predictive of reoperation. Two hundred seventeen patients met enrollment criteria (mean follow-up, 62.5 ± 43.1 months; range, 12-184), of which 163 (75.1%) underwent ORIF and 54 (24.9%) underwent PA. Results: Overall and including planned procedures, patients treated with ORIF had a significantly higher rate of return to the operation room (75.5%) as compared to those in the PA group (31.5%, P < .001). When excluding planned hardware removal, however, there was no difference in reoperation rates between the 2 groups (29.5% in the ORIF group and 29.6% in the PA group, P = 1). Risk factors correlating with unplanned return to the operation room included deep infection (P = .009-.001), delayed wound healing (P = .008), and high-energy trauma (P = .01). Conclusion: When excluding planned removal of hardware, patients with Lisfranc injuries treated with ORIF did not demonstrate a higher rate of reoperation compared with those undergoing PA. Level of Evidence: Level III, retrospective comparative study

The added value of cross-sectional imaging in the detection of additional radiographically occult fractures in the setting of a Chopart fracture

PurposeRadiography has a low sensitivity for the detection of fractures related to the talonavicular and calcaneocuboid articulations, also known as Chopart fractures. The purpose of this study is to determine the sensitivity of radiographs for detecting additional foot and ankle fractures related to Chopart fracture using CT or MRI as the reference standard.MethodWe performed an IRB-approved, retrospective review of radiology reports between 2010 and 2014. Inclusion criteria were (1) diagnosis of a Chopart fracture and (2) at least one radiograph and subsequent cross-sectional imaging (CT or MR). CT or MRI was considered the diagnostic reference standard. Results were stratified by the energy of trauma and by type of radiograph performed (weight-bearing (WB) versus non-WB).ResultsOne hundred eight patients met the inclusion criteria. The calcaneocuboid articulation was the most commonly involved type of Chopart fracture, seen in 75% of cases (81/108). Chopart fractures were detected on the initial radiographs in 67.6% of cases (73/108). Additional fractures of the ankle and midfoot were diagnosed in 34.2% of cases (37/108), with 56.7% (21/37) of these cases having at least one additional fracture seen on CT or MRI that was not seen on the initial radiographs, with fractures of the midfoot most often missed. In 56.7% (17/30) patients whose radiographs detected Chopart fractures, atxa0least one additional fracture was missed; 30% of them demonstrated intra-articular extension and 56.7% were considered displaced.xa0High-energy trauma was related to higher incidence of additional fractures. There was no significant difference in the sensitivity of radiographs to detect additional fractures between high versus low-energy trauma (pu2009=u20090.3) and WB versus non-WB radiographs (pu2009=u20090.5). Most patients were treated nonoperatively (56.5%, 61/108), with surgical intervention more frequent in patients with a high energy of trauma (51.7% versus 33.3%, pu2009=u20090.05).ConclusionIn the setting of a Chopart fracture, CT or MRI can add significant value in the detection of additional ankle or midfoot fractures, irrespective of the energy of trauma. Since additional fractures can have important management implications, CT or MRI should be considered as part of the standard workup for all midfoot fractures.

Optimal Fixation of Jones Fractures Sacrifices the Peroneal Brevis Tendon Insertion andthe Plantar Fascia

Objectives: Patients with Jones fractures (JF) frequently undergo operative management with intramedullary screw fixation. Screw insertion through the base of the fifth metatarsal potentially compromises attachment points of the plantar fascia (PF) and peroneal brevis tendon (PB), and appropriate screw length and diameter remains controversial. The aim of this study was to define the anatomy of the fifth metatarsal bone using CT modeling in order to provide better guidance regarding optimized screw insertion point, screw length, diameter, and thread length and, moreover, to give better insight in the possible compromise of the PB and PF when placing a screw. Methods: Following IRB approval, 21 cadaveric fifth metatarsal bones were harvested. Three reference screws (1mm diameter) were placed and secured on each bone, with 2 screws distally and 1 screw proximally, to act as a geographic register. All bones were CT scanned to create 3D reconstructions using modeling software (Rhinoceros, v5.0). The outer cortex, intramedullary canal and articular cortex of each bone were identified. Using a digitizer (MircoScribe, G2LX), the PB and PF insertions, alongside the reference screws, were mapped onto the corresponding specimen. The total length of the bone, the shape and diameter at the narrowest point of the intramedullary canal were also measured.. Optimal screw diameter and length were calculated in this position, and the impact of screw placement on the insertion sites of both the PB and PF was recorded. Results: The mean length of the bones was 74 ± 3.6mm, with the narrowest diameter of the intramedullary canal being 4.3 ± 0.7 mm. Ideal screw position was identified as parallel to the cuboid and coaxial with the intramedullary cortex, partially sacrificing the PB and PF insertions in 62% (13/21) and 33% (7/21)of specimens respectively, with an average sacrified area of 1.6 ± 0.8 mm of the PB and 1.3 ± 0.8 mm of the PF insertion. The ideal screw length was 48 ± 5.8 mm, with a minimal thread length of 28 ± 6.8 mm and a minimal diameter of 4.5 mm. The screw length:total bone length ratio was 0.64 (range .050-0.72). Conclusion: To maximize compression and pull-out strength, as well as minimize destruction of soft tissue insertions during screw placement for the treatment of JF, screws should be placed parallel to the cuboid and collinear with the intramedullary cortex—mitigating but not avoiding injury to the PB and PF. Average optimal length of the screw should cover 64% of the length of the bone, with a minimum 4.5 mm diameter and 50% thread length. Given variability in anatomy, however, screw choice should be tailored to the individual. Operative treatment of JF, a common foot injury, represent one of the more controversial surgical techniques in foot care today. Improving anatomic understanding of the implications of screw insertion will be paramount to maximizing functional outcomes.