Brad D. Blankenhorn

Factors Affecting the Outcomes of Uncomplicated Primary Open Ankle Arthrodesis

Background: The objective of this study was to identify factors influencing operative outcomes in straightforward, uncomplicated open ankle fusions. Methods: We reviewed all primary open ankle fusions conducted at 1 institution over an 11-year period to identify straightforward, uncomplicated open ankle fusions. Inclusion required a minimum of 6 months follow-up. Patients were excluded for neuropathic arthropathy, insensate limb, failed total ankle replacement, simultaneous arthrodesis of the subtalar joint, or fusions performed within 1 year of injury to salvage failed fixation and painful function due to (1) open fractures, (2) segmental bone loss greater than 1 cm, (3) infection, or (4) talar body fractures. The primary outcome variable was radiographic union at 6 months. Other operative complications were analyzed as secondary outcomes. Five hundred twenty-eight ankle fusion surgeries were performed on 440 patients at 1 institution during the study period. Two hundred fifteen surgeries met inclusion/exclusion eligibility criteria for uncomplicated open ankle fusions. Results: The overall union rate was 91%. In this cohort of uncomplicated open ankle fusions, bivariate analysis over a broad range of potential factors and further focused multivariate analysis found that nonunion was more than 3 times more likely to occur after previous subtalar fusion, and 2 times more likely to occur in patients with preoperative varus ankle alignment. The rate of reoperation was 19%, with nonunion revision as the leading reason, followed by hardware removal and incision and drainage for presumed infection. Diabetes was not a significant risk factor of either deep or superficial infection. Conclusion: Open ankle fusion failed in 9% of uncomplicated ankles with arthritis. Patients who had an open ankle fusion done after previous subtalar joint fusion, as well as those who had preoperative varus ankle alignment, had a significantly higher rate of nonunion. Level of Evidence: Level III, retrospective comparative study.

A biomechanical evaluation of locked plating for distal fibula fractures in an osteoporotic sawbone model

BACKGROUND Supination external rotation (SER) injuries are commonly fixed with a one third tubular neutralization plate. This study investigated if a combination locked plate with additional fixation options was biomechanically superior in osteoporotic bone and comminuted fracture models. METHODS Using an osteoporotic and a comminuted Sawbones model, SER injuries were fixed with a lag screw for simple oblique fibula fractures, and either a one third tubular neutralization plate or a locking plate. Samples were tested in stiffness, peak torque, displacement at failure, and torsion fatigue. RESULTS There was no statistically significant difference in biomechanical testing for fractures treated with a lag screw and plate. For comminuted fractures, locked plating demonstrated statistically significant stiffer fixation. CONCLUSION A combination locked plate is biomechanically superior to a standard one third tubular plate in comminuted SER ankle fractures. There was no biomechanical superiority between locked and one third tubular plates when the fracture was amenable to a lag screw.

What is the Role and Limit of Calcaneal Osteotomy in the Cavovarus Foot

Calcaneal osteotomy is a commonly used tool in cavovarus foot reconstructions. Understanding the indications and limitations of such an osteotomy is critical to success in reconstruction. We present a comprehensive review of surgical calcaneal osteotomy techniques and the currently available state of literature for their indications and limitations.

Correction of Metatarsus Primus Varus Associated With Hallux Valgus Deformity Using the Arthrex Mini TightRope A Report of 44 Cases

Metatarsus primus varus must be addressed during correction of moderate to severe hallux valgus deformity. As an alternative to proximal osteotomy or first tarsometatarsal fusion for hallux valgus correction, this study presents a series of patients treated using the Arthrex Mini TightRope. A total of 36 patients (44 operations) with hallux valgus and metatarsus primus varus underwent correction using the Arthrex Mini TightRope. Assessment included measurement of radiographic parameters, the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot outcomes score, and the SF-12. The average hallux valgus angle improved from 32.2° to 15.2° (P < .0001). The average first intermetatarsal angle improved from 14.6° to 8.2° (P < .0001). The average distal metatarsal articular angle improved from 17.0° to 9.6° (P < .0001). The average AOFAS midfoot outcomes scores improved from 45.44 to 84.72 (P < .0001). Postoperative SF-12 physical and mental scores averaged 52.99 and 56.63. Only one patient had recurrence of deformity. Correcting metatarsus primus varus in association with hallux valgus deformity using the Arthrex Mini TightRope should be considered a treatment option. This technique is less invasive and seems capable of maintaining correction while allowing for early weight bearing and avoiding the need for a proximal first metatarsal osteotomy or Lapidus procedure.

Neurologic Deficit Associated With Lateralizing Calcaneal Osteotomy for Cavovarus Foot Correction

Background: Lateralizing calcaneal osteotomy (LCO) is a frequently used technique to correct hindfoot varus deformity. Tibial nerve palsy following this osteotomy has been described in case reports but the incidence has not been quantified. Methods: Eighty feet in 72 patients with cavovarus foot deformity were treated over a 6-year span by 2 surgeons at their respective institutions. Variations of the LCO were employed for correction per surgeon choice. A retrospective chart review analyzed osteotomy type, osteotomy location, amount of translation, and addition of a tarsal tunnel release in relation to the presence of any postoperative tibial nerve palsy. Tibial nerve branches affected and the time to resolution of any deficits was also noted. Results: The incidence of neurologic deficit following LCO was 34%. With an average follow-up of 19 months, a majority (59%) resolved fully at an average of 3 months. There was a correlation between the development of neurologic deficit and the location of the osteotomy in the middle third as compared to the posterior third of the calcaneal tuber. We found no relationship between the osteotomy type, amount of correction, or addition of a tarsal tunnel release and the incidence of neurologic injury. Conclusions: Tibial nerve palsy was not uncommon following LCO. Despite the fact that deficits were found to be transient, physicians should be more aware of this potential problem and counsel patients accordingly. To decrease the risk of this complication, we advocate extra caution when performing the osteotomy in the middle one-third of the calcaneal tuberosity. Although intuitively the addition of a tarsal tunnel release may protect against injury, no protective effect was demonstrated in this retrospective study. Level of Evidence: Level III, retrospective cohort study.

Biomechanical Evaluation of Mini-Fragment Hardware for Supination External Rotation Fractures of the Distal Fibula

Background. Supination external rotation distal fibula fractures are common, requiring fixation when associated with talar displacement. Subcutaneous distal fibula hardware may become painful, necessitating operative removal. We hypothesize that mini-fragment and small-fragment constructs will demonstrate similar biomechanical stability. Methods. A biomechanical comparison was performed in synthetic osteoporotic sawbones. The first arm compared two 2.4-mm lag screws with one 3.5-mm lag screw for fixation of a simulated supination external rotation distal fibula fracture. The second arm compared a 2.4-mm plate-screw construct with a 3.5-mm lag screw and one-third tubular neutralization plate. During torsional testing, torque and displacement were recorded, and stiffness and peak torque were determined. Results. Differences in mean stiffness and mean load at failure were not statistically significant with lag screw–only fixation. The 3.5-mm plate-screw construct outperformed the 2.4-mm plate-screw construct, but neither mean stiffness nor mean load at failure were statistically significantly different. Dynamic testing also demonstrated similar results. Conclusion. Our data suggest that isolated 2.4-mm screws function similarly to one 3.5-mm screw. Although the 3.5-mm plate-screw construct was stiffer, mean load at failure was equivalent for the 2 constructs. These data provide biomechanical evidence to support further investigation in the use of mini-fragment hardware for distal fibula fracture fixation. Levels of Evidence: Therapeutic, Level V

Evaluation of saline load test for simulated traumatic arthrotomies of the ankle

INTRODUCTION A tool frequently used for evaluation of a traumatic arthrotomy is the saline load test. No information exists in the current literature guiding what baseline fluid infusion is required to reliably detect or diagnose a traumatic ankle arthrotomy. The purpose of this study was to provide a reliable benchmark when employing the saline load test for complex ankle soft-tissue wounds with suspected intra-articular involvement. MATERIALS AND METHODS Twenty-one consecutive patients presenting for elective ankle arthroscopy underwent simulated saline load tests. After placement of an approximately 4-mm standard lateral portal, an 18-gauge needle was inserted into the anteromedial ankle joint and normal saline was injected until frank extravasation from the lateral arthrotomy was observed. The amount of saline required to diagnose a simulated traumatic arthrotomy was recorded. RESULTS The average amount of normal saline that resulted in extravasation was 10.3 cm(3). In order to identify 90% and 95% of simulated ankle arthrotomies, 23 and 30 cm(3) of saline were required, respectively. The average preoperative range of motion did not correlate with saline infusion requirements (r(2)=0.013368). CONCLUSIONS Based on these results, a minimum infusion of 30 cm(3) is recommended to identify 95% of traumatic arthrotomies approximately 4mm in size. This value needs to be interpreted with the understanding that this study is limited by its inherently simulated nature. An infusion of 30 cm(3) represents a relatively safe and reasonable standard to apply to any potential ankle injury in which joint violation remains in question.

Clinical Tip: One Stage Lengthening of Fourth Brachymetatarsia Using Fibular Autograft

Level of Evidence: V, Expert Opinion

Use of a Pin Distractor as an Aid for Fixation of Pronation-External Rotation Fibular Fractures

Restoration of fibular length in pronation and other comminuted ankle fractures is key to good clinical outcomes and is often a challenging aspect of open reduction and internal fixation of the fibula. This article reports the use of a pin distractor to achieve appropriate fibular reduction in otherwise challenging ankle fractures. The authors describe the use of a pin distractor to obtain length and minimize the number of surgical assistants needed for these challenging ankle fractures. The authors find this technique particularly useful with pronation type and subacute ankle fractures. [Orthopedics. 2017; 40(1):e192-e194.].

Peroneal Tendon Pathology

The lateral compartment musculo-tendinous units can be a frequent source of pain and instability following trauma. Radiographic signs may be helpful in making diagnosis; however, advanced imaging modalities are often helpful.