Arthur K. Walling

Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification.

From January 1987 to September 1990, 132 displaced intraarticular calcaneal fractures were treated operatively using a lateral approach, lag screws, and side plate without bone graft. To evaluate the results, a classification for intraarticular calcaneal fractures was developed, based on standardized coronal and transverse computed tomography (CT) scans of both feet. Type I fractures were nondisplaced (and received nonoperative treatment); Type II were two-part or split fractures; Type III were three-part or split depression fractures; and Type IV were four-part or highly comminuted articular fractures. Results were evaluated using the Maryland Foot Score and repeat CT scans. One hundred twenty cases were available for a minimum of one year follow-up evaluation (range, 12–56 months; mean, 29.3 months). Roentgenographic evaluation of calcaneal body dimensions showed restoration of heel height (98%), width (110%), and length (100%) to virtually normal in all cases, regardless of preoperative displacement. Roentgenographically, articular reduction was anatomic in 68 of 79 (86%) Type II fractures, 18 of 30 (60%) Type III fractures, and 0 of 11 (0%) Type IV fractures. Excellent or good clinical results occurred in 58 of 79 (73%) Type II fractures, 21 of 30 (70%) Type III fractures, and one of 11 (9%) Type IV fractures. When excellent and good clinical results were compared by year, a distinct learning curve appeared (1987, 27%; 1988, 54%; 1989, 74%; 1990, 84%). Despite an improved outcome for Type II and III fractures with increasing surgical experience, the results of operative intervention in Type IV fractures were no better, even after four years. This classification aids the surgeon in perioperative decision making, because it has prognostic significance. Results deteriorate as the number of articular fragments increase. This appears to be directly related to the difficulty obtaining an anatomic reduction of the joint. Furthermore, although an anatomic articular reduction is necessary for a good result, it does not guarantee it. Additionally, a learning curve exists for surgeons engaged in operative surgery of Type II and III fractures. Patients with Type IV fractures can expect inferior operative results irrespective of the surgeons experience, and consideration should be given to primary arthrodesis.

Prospective Controlled Trial of STAR Total Ankle Replacement versus Ankle Fusion: Initial Results

Background: Mobile-bearing ankle replacements have become popular outside of the United States over the past two decades. The goal of the present study was to perform a prospective evaluation of the safety and efficacy of a mobile-bearing prosthesis to treat end stage ankle arthritis. We report the results of three separate cohorts of patients: a group of Scandanavian Total Ankle Replacement (STAR) patients and a control group of ankle fusion patients (the Pivotal Study Groups) and another group of STAR total ankle patients (Continued Access Group) whose surgery was performed following the completion of enrollment in the Pivotal Study. Materials and Methods: The Pivotal Study design was a non-inferiority study using ankle fusion as the control. A non-randomized multi-centered design with concurrent fusion controls was used. We report the initial perioperative findings up to 24 months following surgery. For an individual patient to be considered an overall success, all of the following criteria needed to be met: a) a 40-point improvement in total Buechel-Pappas ankle score, b) no device failures, revisions, or removals, c) radiographic success, and d) no major complications. In the Pivotal Study (9/00 to 12/01), 158 ankle replacement and 66 arthrodesis procedures were performed; in the Continued Access Study (4/02 to 10/06), 448 ankle replacements were performed, of which 416 were at minimum 24 months post-surgery at time of the database closure. Results: Major complications and need for secondary surgical intervention were more common in the Pivotal Study arthroplasty group than the Pivotal Study ankle fusion group. In the Continued Access Group, secondary procedures performed on these arthroplasty patients decreased by half when compared with the Pivotal Arthroplasty Group. When the Pivotal Groups were compared, treatment efficacy was higher for the ankle replacement group due to improvement in functional scores. Pain relief was equivalent between fusion and replacement patients. The hypothesis of non-inferiority of ankle replacement was met for overall patient success. Conclusion: By 24 months, ankles treated with STAR ankle replacement (in both the Pivotal and Continued Access Groups) had better function and equivalent pain relief as ankles treated with fusion. Level of Evidence: II, Prospective Controlled Comparative Surgical Trial

Subtalar Arthrodesis for Complications of Intra-articular Calcaneal Fractures

Eighty six subtalar arthrodeses performed between 1985 and 1996 for complications associated with intra-articular calcaneal fractures were retrospectively evaluated. Patients were divided into three Groups: (I) 59 patients with calcaneal malunions (II) 13 patients with failed open reduction and internal fixation, and (III) eight patients undergoing open reductions and primary fusion for highly comminuted fractures. In each scenario, internal fixation was achieved with cancellous lag screws. Bone graft material consisted of either autogenous iliac crest graft, local graft obtained from the lateral wall exostectomy of the malunion, or freeze-dried cancellous allograft. Fusions in Groups II and III were performed in situ. Fusions in Group I were performed either in situ or utilizing a variety of reconstructive procedures depending upon the type of malunion encountered. Eighty three of the 86 fusion attempts were successful following the initial operations for a union rate of 96%. Fusion rates were similar regardless of the graft material used. Complications included four varus malunions, four cases of osteomyelitis, and two cases of reflex sympathetic dystrophy. A statistically significant shorter hospital stay was found for patients not undergoing iliac crest bone graft procedures. Eighty patients with at least two year follow up achieved a mean American Orthopaedic Foot and Ankle Society(AOFAS) ankle-hindfoot score of 75.0. Scores were similar for all three groups and for the various types of reconstructive procedures used. No correlation was found between postoperative talar declination angle and the AOFAS ankle-hindfoot score. Workers compensation patients tended to have a poorer clinical outcome.

Operative Treatment of Calcaneal Fractures in Elderly Patients

BACKGROUND Operative intervention is an accepted treatment for fractures of the calcaneus. However, the literature discourages surgery for these fractures in the elderly. The purpose of this paper was to review the outcomes of surgical treatment of displaced fractures of the calcaneus in elderly patients. METHODS Between November 1987 and June 2000, forty-two patients (forty-four fractures) who were sixty-five years of age or older underwent surgery for a calcaneal fracture. The mechanism of injury, fracture pattern, and medical comorbidities were recorded. Thirty-five patients with a total of thirty-seven fractures were available for follow-up, which was conducted with physical and radiographic examinations and outcomes assessment with the Short Form-36 (SF-36), the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, and the Short Musculoskeletal Function Assessment survey. RESULTS The minimum duration of follow-up was two years, and the average duration was forty-four months. All but one fracture (97% of the fractures) healed at an average of 110 days. The average active range of motion was 38 degrees of plantar flexion, 10 degrees of dorsiflexion, 16 degrees of inversion, and 11 degrees of eversion. The average American Orthopaedic Foot and Ankle Society score was 82.4 points, the average SF-36 score was 52.8 points, and the average Short Musculoskeletal Function Assessment score was 20.4 points. Posttraumatic subtalar arthritis developed in twelve patients. There were twelve minor complications and four major complications (three cases of osteomyelitis and one nonunion), all of which were treated successfully. CONCLUSIONS Open reduction appears to be an acceptable method of treatment for displaced calcaneal fractures in elderly patients. Careful patient selection is necessary because individuals presenting with severe osteopenia, those who are unable to walk or are able to walk only about the house, and those with a medical condition that precludes surgery may be better candidates for nonoperative care.

Anterior plate supplementation increases ankle arthrodesis construct rigidity.

Background: The success of ankle arthrodesis for the treatment of post-traumatic ankle arthritis depends on achieving and maintaining rigid fixation of the prepared tibiotalar interface. The purpose of this study was to examine the biomechanical effect of anterior plate supplementation of a popular three-screw fusion construct. Methods: Six fresh-frozen cadaver ankles were prepared and instrumented with three partially threaded screws compressing the tibiotalar interface. Testing was done with and without supplementary anterior plate fixation under three different decoupled loading conditions: plantarflexion/dorsiflexion, inversion/eversion, and rotation. Motion at the tibiotalar interface was recorded. Results: Anterior plating increased construct stiffness by a factor of 3.5, 1.9, and 1.4 for the sagittal, coronal, and torsion modes, respectively. Less motion occurred at the tibiotalar interface in all to the three different loading conditions (p = 0.031) with plate supplementation. Conclusions: Compared to screws alone, anterior plate supplementation increases construct rigidity and decreases micromotion at the ankle fusion interface.

The Use of Tricortical Autograft Versus Allograft in Lateral Column Lengthening for Adult Acquired Flatfoot Deformity: An Analysis of Union Rates and Complications

Background: The management of adult acquired flatfoot is an evolving practice with the optimal lateral column lengthening procedure still left to considerable debate. The usual choices include lengthening with the use of autograft or allograft through a calcaneocuboid lengthening arthrodesis or Evans’ calcaneal lengthening osteotomy. To our knowledge there is only one other study comparing autograft to allograft in adult lateral column lengthening procedures. 9 The purpose of this study was to evaluate differences with regard to union rates and complications when comparing the use of iliac tricortical autograft versus iliac tricortical allograft supplemented with platelet rich plasma (PRP) in adult acquired flatfoot lateral column lengthening procedures. Materials and Methods: The charts and radiographs of 49 patients (51 feet) were evaluated. Twenty total procedures were performed using iliac tricortical autograft and 31 procedures were performed using iliac tricortical allograft with PRP. Results: Successful union was achieved in 14 of 20 (70%) autograft procedures and 29 of 31 (94%) allograft procedures. Thirteen of 20 (65%) of the autograft group and 11 of 31 (35%) of the allograft group had a documented complication other than nonunion. Average length of hospital stay for patients who had procedures using autograft was 3.6 days and those who had allograft was 2.5 days. The average charge for those receiving allograft with PRP, including hospital stay, was roughly

Subungual Exostosis: A Simple Technique of Excision

2,500 more than those receiving an autograft procedure. Conclusion: Although the numbers were small, we believe that equivalent if not better healing and complication rates are possible with the use of allograft with PRP versus autograft for lateral column lengthening procedures while allowing for similar correction of deformity. Level of Evidence: III, Case Control Study

The Adult Clubfoot (Congenital Pes Cavus)

Subungual or Dupuytrens exostosis is a benign lesion of the distal phalanx that is prone to recurrence if incompletely excised. We report on a series of five patients treated with our simple excision technique. Despite sacrifice of a portion of the nail bed, the cosmetic appearance of the nail was excellent in four patients and good in one patient. There were no recurrences.

Subtalar repositional arthrodesis for adult acquired flatfoot

Clubfoot occurs in approximately 1 of every 1000 live births, with multiple theories proposed regarding the cause. The pathologic anatomy of the adult clubfoot consists of four components (cavus, adductus, varus, and equinus) and the specific soft tissue and bony procedures indicated for correction depend completely on the constellation of residual deformity that may exist. If the patient was successfully treated at a younger age and has only limited deformity, all that may be required is symptomatic treatment or bracing. Flexible deformities may be treated with a combination of soft tissue procedures and osteotomies or limited fusions, which will not compromise the essential joints of the ankle, subtalar, and talonavicular joints. More rigid deformities require fusions with their associated functional loss, in an attempt to obtain a plantigrade foot.