Armen S. Kelikian

Charcot Ankle Fusion with a Retrograde Locked Intramedullary Nail

Twenty patients with severe neuropathic (Charcot) ankle deformities underwent 21 attempted ankle fusions with a retrograde locked intramedullary nail as an alternative to amputation. All had insensate heel pads and had failed at nonoperative methods of accommodative ambulatory bracing. In 11, the talus was either absent, or the deformity was of sufficient magnitude to require talectomy to align the calcaneus under the tibia for plantigrade weightbearing. Ages ranged from 28 to −68 (average 56.3) years. Nineteen were diabetic, 12 being insulin-dependent. Their average body weight was 102 kg, with 11 greater than 90 kg at the time of surgery. Eight had chronic large full thickness ulcers overlying, but not involving bone of the medial malleolus, medial midfoot, or proximal fifth metatarsal, at the time of surgery. At a follow-up of 12 to 31 months, 19 achieved bony fusion. In the 10 patients where talectomy was not required, fusion was achieved at an average of 5.3 months without complications. In the patients who required talectomy, six of the patients required eight additional operations to achieve fusion. Three achieved fusion following removal of the nail and prolonged bracing. One opted for ankle disarticulation for chronic persistent infection, rather than attempt reoperation. One died of unrelated causes during the early postoperative period. Retrograde locked intramedullary ankle fusion is a reasonable alternative to amputation in the neuropathic (Charcot) ankle that cannot be controlled with standard bracing techniques. The potential for morbidity requiring reoperation is greatly increased when the deformity is of sufficient magnitude to require talectomy to achieve alignment of the calcaneus in a plantigrade weight-bearing position under the tibia or when there are large open ulcers.

Arthroscopically Assisted Autologous Osteochondral Transplantation for Osteochondral Lesions of the Talar Dome: An MRI and Clinical Follow-Up Study

Osteochondral Lesions of the Talar Dome (OLT) are common problems encountered in orthopedics. Although the etiology remains uncertain, a myriad of treatment options exists. The authors describe arthroscopically assisted autologous osteochondral graft (OCG) transplantation procedures in the treatment of unstable OLTs in nine patients. The patients underwent standard preoperative MRI examination to assess fragment stability (using De Smet criteria for stability). Intraoperative arthroscopy was used to correlate the preoperative MRI assessment (using Cheng/ Ferkel grading). After transplantation procedures, MRI (using De Smet criteria for stability) assessed graft incorporation for stability at an average of 9.3 months after the procedure. Preoperative MRI correlated highly with arthroscopic findings of OLT instability (sensitivity = 1.0). This has been demonstrated in the current orthopedic literature. The post transplantation MRI demonstrated stable graft osteointegration by De Smet criteria in all patients. Postoperative visual analogue pain scales showed significant improvement from preoperative assessment. Postoperative AOFAS Ankle-Hindfoot scores averaged 80.2 (S.D. +/− 18.9). Our favorable early results and those of other authors using similar techniques may validate OCG transplantation as a viable alternative for treating unstable osteochondral defects in the talus that are refractive to more commonly used surgical techniques.

Outcome of the modified Broström procedure for chronic lateral ankle instability using suture anchors.

The modified Broström procedure is an anatomic reconstruction of the lateral ankle ligaments. The present study evaluated twenty-two patients (mean age = 27.2 years) with chronic lateral ankle instability who underwent surgical repair of their lateral ankle ligaments using suture anchors as part of the modified Broström procedure. All surgeries were performed by the senior author (AK) on an outpatient basis. At a mean follow-up of 34.5 months (minimum of 18 months), twenty patients (91%) reported a good or excellent functional outcome as assessed by the Karlsson and Peterson ankle function scoring scale. 21 One patient developed a superficial wound infection post-operatively that was eradicated with a course of oral antibiotics. Sixteen of the twentytwo patients were available for follow-up physical examination and stress radiographs. Fourteen of the sixteen patients had no evidence of instability on physical examination or on stress radiographs. One patient had diminished sensation in the superficial peroneal nerve distribution. Five of the sixteen patients had generalized ligamentous laxity; none of these patients had an excellent result, and they had lower “Overall Satisfaction” scores (P = 0.013). We conclude that the use of suture anchors is a simple and effective adaptation of the modified Broström procedure, which results in a good or excellent outcome in the majority of patients with few complications.

Anterior Tibialis Tendon Ruptures: An Outcome Analysis of Operative Versus Nonoperative Treatment

Ruptures of the anterior tibialis tendon are a rare clinical entity. Case reports in the literature reveal a total of 28 cases. Unfortunately, because of the limited discourse in the orthopaedic literature, there are few guidelines regarding the treatment for these injuries. This study analyzes the treatment of 16 anterior tibialis tendon ruptures. Eight patients in this group had operative treatment of their ruptures, and eight patients had nonsurgical treatment of their ruptures. The average follow-up for the operative and nonoperative patients were 6.68 years and 3.86 years, respectively. The Foot and Ankle Outcome questionnaire provided by the American Academy of Orthopaedic Surgeons and an outcome-based foot score described by Kitaoka et al. were used as the methods of analysis. Our outcome results show no statistically significant difference between operative and nonoperative treatment in anterior tibialis tendon ruptures. The lack of statistical difference between operative and nonoperative groups may be a reflection of the age bimodality present in this study. Elderly low demand patients were treated nonsurgically and young active patients were treated operatively. Therefore, despite a lack of statistical difference present in the outcome of both groups, we still maintain the need to repair/reconstruct anterior tibialis tendon ruptures in young active patients with high functional demands. The deficits present in the nonoperative group, we believe, would not be well tolerated in a young high functional demand patient. Nonsurgical management is an appropriate alternative in low demand elderly patients.

Ultrasound diagnosis of peroneal tendon tears: A surgical correlation

BACKGROUND Musculoskeletal ultrasound is an established diagnostic technique for the assessment of tendon injuries. The purpose of the present study was to determine whether ultrasound is effective for evaluating peroneal tendon injuries, with surgical findings used as the standard of reference. METHODS Fifty-eight patients with a suspected peroneal tendon injury were prospectively evaluated with use of dynamic ultrasound. Twenty-five patients were found to have peroneal tendon tears and were managed operatively. Five patients with normal peroneal tendons on ultrasound examination also were managed operatively for other reasons and are included in the series as the peroneal tendons were inspected at the time of the procedure. Ultrasound and surgical criteria were used to grade the peroneal tendons on a scale from grade 0 (normal tendon) to grade III (tendon rupture). RESULTS Of the sixty tendons that were evaluated operatively, twenty-five were found to be torn. The sensitivity, specificity, and accuracy of ultrasonography were 100%, 85%, and 90%, respectively. CONCLUSIONS The use of dynamic ultrasound is effective for determining the presence or absence of a peroneal tendon tear and should be considered a first-line diagnostic tool.

Fresh osteochondral allograft for the treatment of cartilage defects of the talus: a retrospective review.

BACKGROUND Osteochondral lesions of the talar dome can cause substantial functional impairment and present a difficult treatment dilemma. Interest has recently focused on fresh osteochondral allografts as a promising treatment alternative. The purpose of this study was to evaluate the clinical outcome of osteochondral lesions of the talus treated with a fresh osteochondral allograft. METHODS We performed a transfer of fresh osteochondral allograft in forty-two patients with a symptomatic, refractory osteochondral lesion of the talus. Complete postoperative follow-up was achieved for thirty-eight patients with an average age of 44.2 years. Clinical evaluation was performed with use of the American Orthopaedic Foot & Ankle Society ankle-hindfoot score and a visual analog pain scale. All scores were obtained from either a retrospective chart review or a direct patient interview. All patients were also asked about their subjective satisfaction with the procedure. Magnetic resonance images were acquired for fifteen patients, to assess graft incorporation, subsidence, articular cartilage congruity, osteoarthritis, and stability with use of the De Smet criteria. RESULTS The average duration of follow-up after osteochondral allograft transplantation was 37.7 months. Graft failure occurred in four patients. With the inclusion of scores before revision for those with graft failure, the mean visual analog pain scale score improved from 8.2 to 3.3 points, and the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot score improved from 52 to 79 points. Patient satisfaction with the outcome was rated as excellent, very good, or good by twenty-eight of the thirty-eight patients and as fair or poor by ten patients. Of the fifteen magnetic resonance imaging scans, most showed minimal graft subsidence, reasonable graft stability, and persistent articular congruence. CONCLUSIONS In our experience, transplantation of fresh osteochondral allograft is a viable and effective method for the treatment of osteochondral lesions of the talus as evidenced by improvements in pain and function.

Tarsal Tunnel Syndrome: Diagnosis, Surgical Technique, and Functional Outcome*:

During a 10-year period, 47 patients underwent surgical management for tarsal tunnel syndrome (TTS). Of these, 34 (36 feet) were available for complete retrospective analysis by record review, questionnaire, and physical examination. An additional 10 patients were evaluated by record review alone. The mean age was 38 years (range, 12–65 years). Overall, average follow-up was 35 months (range, 15–102 months). All patients had nonsurgical care for an average of 16 months before surgery (range, 1–72 months). The symptom triad of pain, paresthesias, and numbness was the most common clinical presentation. All had a positive Tinels sign and nerve compression test (NCT) at the tarsal tunnel. Electrodiagnostic studies were abnormal in 38 feet (81%). Two-point discrimination was diminished significantly by an average of 6.7 mm. At a follow-up examination two-point discrimination improved by an average of 3.8 mm (P < 0.001). Eighteen feet continued to have a positive Tinels sign and had a residual NCT. Subjectively, patients were satisfied with the surgical outcome in 72% of the cases. Postoperative improvement in the median Symptom Severity Score and the Functional Foot Score reflected this satisfaction. The perioperative complication rate was 30%. We conclude that the diagnosis of TTS is made primarily on history and clinical evaluation with electrodiagnostic studies supporting the diagnosis in 81%. Surgical treatment is warranted after nonsurgical management has failed. Division of the deep portion of the abductor hallucis fascia is important to ensure a complete release.

Cost-Effectiveness Comparison of Three Methods of Internal Fixation for Arthrodesis of the First Metatarsophalangeal Joint:

We used decision-analysis modeling to determine the most cost-effective fixation device among Herbert screws, AO screws, and the Luhr plate for first metatarsophalangeal joint arthrodesis. The model considered patient-reported outcomes at minimum 2-year follow-up, patient charges for the entire course of care, and event and outcome incidences within each fixation group. AO screws had the lowest average cost of utility and, therefore, are the most cost-effective fixation device for first metatarsophalangeal joint arthrodesis even though utility is highest with the Luhr plate. Operating room costs and union rate most strongly influenced cost-effectiveness.

Plantar Forefoot Pressure Changes After Second Metatarsal Neck Osteotomy

Background: The aim of this study was to evaluate plantar pressure changes after second metatarsal neck osteotomy using the Weil technique. Methods: Six below-knee cadaver specimens were used. Each specimen was held in a custom-built apparatus and loaded to 500 N for a period of 3 seconds. Using a computerized Musgrave pedobarograph, pressure measurements were made before and after osteotomy in both neutral and 45-degree heel rise positions. All osteotomies were made at an angle of approximately 20 degrees relative to the long axis of the metatarsal shaft. The metatarsal heads were displaced proximally by 5 mm and fixed with a single Kirschner wire. Results: After osteotomy there was an average decrease in pressure beneath the second metatarsal from 70.6 to 45.1 kPa in neutral and from 813.0 to 281.4 kPa in heel rise, representing statistically significant (p ≤ 0.05) decreases of 36% and 65%, respectively. There also were significant decreases beneath the third metatarsal in both neutral (39%) and heel rise (37%), and beneath the fourth metatarsal in neutral position (28%). A significant pressure increase occurred beneath the first metatarsal in neutral (23%). No significant pressure changes occurred under the fifth metatarsal in either position. Conclusion: Overall, our results indicated that the Weil metatarsal neck osteotomy is effective at offloading the second metatarsal head at neutral and heel rise positions.

The role of computed tomography and radionuclide scintigraphy in the localization of osteomyelitis in flat bones

The combined use of radionuclide scintigraphy and computed tomography is recommended for evaluating children with laboratory and clinical data suggestive of flat bone osteomyelitis despite normal conventional radiographs. In addition, computed tomography may be helpful in the presence of abnormal radiographs in determining the exact location of the focus of osteomyelitis and the most suitable route for appropriate drainage or to obtain culture material.