Bradly W. Bussewitz

Retrograde Intramedullary Nail With Femoral Head Allograft for Large Deficit Tibiotalocalcaneal Arthrodesis

Background: Large bone defects present a difficult task for surgeons when performing single-stage, complex combined hindfoot and ankle reconstruction. There exist little data in a case series format to evaluate the use of frozen femoral head allograft during tibiotalocalcaneal arthrodesis in various populations in the literature. Methods: The authors evaluated 25 patients from 2003 to 2011 who required a femoral head allograft and an intramedullary nail. The average time of final follow-up visit was 83 ± 63.6 weeks (range, 10-265). Results: Twelve patients healed the fusion (48%). Twenty-one patients resulted in a braceable limb (84%). Four patients resulted in major amputation (16%). Conclusion: This series may allow surgeons to more accurately predict the success and clinical outcome of these challenging cases. Level of Evidence: Level IV, case series.

Interference Screw Fixation and Short Harvest Using Flexor Digitorum Longus (FDL) Transfer for Posterior Tibial Tendon Dysfunction: A Technique

Posterior tibial tendon dysfunction is a common clinical entity treated by foot and ankle specialists, and numerous surgical treatments are available to the modern foot and ankle surgeon. Fixation methods are constantly evolving as new products are developed and new uses for existing products are attempted. Interference screw fixation is the gold standard fixation for tendon autograft and allograft in orthopedic sports medicine. The technique that we describe in this article uses a less extensive harvest of the flexor digitorum longus tendon and a sound fixation method using an interference screw positioned in the tarsal navicular.

A Multicenter, Retrospective Study of Early Weightbearing for Modified Lapidus Arthrodesis

The modified Lapidus arthrodesis is a long-established surgical technique for management of hallux valgus that provides reproducible results and quality patient outcomes. The data from 367 consecutive patients undergoing unilateral modified Lapidus arthrodesis from January 1, 2007 to December 31, 2008 at participating centers were retrospectively evaluated. The included patients were categorized into early weightbearing (≤ 21 days) and delayed weightbearing (> 21 days) groups. A total of 24 nonunions (6.5%) were identified, with 13 (7.1%) in the early weightbearing group and 11 (6.0%) in the delayed weightbearing group. To date, the present study is the largest multicenter investigation to evaluate early weightbearing after modified Lapidus arthrodesis and the only large study to directly compare early and delayed weightbearing. The findings of the present study have shown that early weightbearing for modified Lapidus arthrodesis does not increase the risk of nonunion when evaluating various fixation constructs.

The Fifth Metatarsal Base: Anatomic Evaluation Regarding Fracture Mechanism and Treatment Algorithms

Fractures occurring within the 1.5-cm proximal portion of the fifth metatarsal are commonly considered avulsion fractures. The exact mechanisms of such fractures are controversial. The present study focused on determining the likely mechanism of fracture according to the exact anatomy to allow for more successful treatment. The research sample included 10 frozen cadaveric specimens. The lateral band of the plantar fascia, peroneus brevis, and articular surface were identified and separated from their attachments, thereby splitting the fifth metatarsal base into zones A, B, and C. In zone A, the attachment of the plantar fascia was 6.6 ± 2.2 mm from the inferior aspect, 9.5 ± 2.9 mm from the proximal aspect, and 11.5 ± 0.9 mm from the lateral aspect. In zone B, the attachment of the peroneus brevis was 12.0 ± 2.2 mm from the inferior aspect, 10.2 ± 2.2 mm from the proximal aspect, and 11.5 ± 0.9 mm from the lateral aspect. Zone C was measured from the border of zone B and encompassed the articulation of the fifth metatarsal to the cuboid. We propose that fractures occurring in the most proximal end of the fifth metatarsal, zone A, are caused by a lateral band of plantar fascia and might be able to be treated conservatively by immobilization with weightbearing. We also propose that fractures occurring in zones B and C result from traumatic tension on peroneus brevis and might need to be treated with strict immobilization and non-weightbearing or open reduction internal fixation.

Intermediate-Term Results Following First Metatarsal Cheilectomy

Hallux rigidus is a term describing degenerative joint disease (DJD) to the first metatarsal phalangeal joint (MTPJ). It is the most common DJD encountered in the foot and is the second most common pathology of the great toe behind hallux valgus. The goal of a cheilectomy is to relieve pain and increase MTPJ motion. Critical evaluation of the cheilectomy must include longevity of desired results. The primary goal of this study was to determine how long a cheilectomy can be expected to last before an arthrodesis or joint destructive procedure is performed, if ever. We examined 189 cheilectomies with a mean radiographic follow-up of 235 days and mean chart review follow-up of 1184 days (3.2 years). Analysis showed 5 repeat cheilectomies, 1 interpositional arthroplasty, and only 2 arthrodeses subsequently performed. This retrospective study provides intermediate term evidence that cheilectomy is an appropriate procedure for stages 1, 2, and 3 first MTPJ DJD with reliable, lasting results. Levels of Evidence: Therapeutic, Level III

Evans Osteotomy and Risk to Subtalar Joint Articular Facets and Sustentaculum Tali: A Cadaver Study

The Evans lateral column lengthening procedure allows correction of abduction, improved talar head coverage, decreased forefoot and rearfoot valgus, and improvement of medial column arch height. However, identifying the structures at risk when performing this osteotomy has proved difficult in vivo. Using 10 cadaveric lower limbs, we performed the Evans calcaneal osteotomy and determined whether violation of the calcaneal facets and the sustentaculum tali occurred. Based on our findings, we recommend directing the osteotomy from posterolateral to anteromedial.

High-pressure Water Injection of the Foot with Associated Subcutaneous Emphysema: A Case Report

A review of the literature yields few reported cases of industrial-strength high-pressure water injection injuries involving the foot, and sources of information for industrial-strength high-pressure water injection injuries reside primarily in the hand surgical literature. Toxic materials, such as grease, paint, and diesel oil, are relatively common agents involved in injection injuries, and these substances are associated with increased morbidity in comparison with injection of water or air. Treatment of high-pressure injection of a toxic substance is a surgical emergency requiring irrigation, debridement, antibiotic administration, and monitoring for signs and symptoms of compartment syndrome. There are, however, documented cases where less extreme treatment regimens have met with success. We report a successful limb salvage case, and review of the literature, related to a high-pressure water injury involving the foot with associated extensive subcutaneous emphysema.

Structures at Risk with Medial Double Hindfoot Fusion: A Cadaveric Study

Although discussed as an alternative to triple arthrodesis for hindfoot correction, the published data surrounding the medial double arthrodesis, or fusion of the subtalar and talonavicular joints, has not addressed the proximity of the anatomic structures at risk. A total of 10 cadaver specimens were used to examine the risk of damage to the neurovascular and tendinous structures of the posterior medial hindfoot when performing the medial double arthrodesis. The distance of the reviewed structures was measured in relation to the standardized point of the middle facet of the calcaneus (mean ± standard deviation and range). The proximity of the middle facet to the posterior tibial tendon was 1.88 ± 2.65 (range 0 to 6.65) mm, to the flexor digitorum longus tendon was 5.34 ± 4.79 (range -3.14 to 12.79) mm, to the flexor hallucis longus tendon was 19.08 ± 4.84 (range 13.04 to 27.31) mm, and to the neurovascular bundle was 21.19 ± 7.84 (range 8.36 to 34.26) mm. At the level of the middle facet, the posterior tibial tendon was the largest tendon, measuring 7.14 ± 2.21 (range 3.31 to 10.23) mm by 2.95 ± 0.88 mm (range 1.86 to 4.24 mm; area 22.37 ± 12.23 mm(2), range 6.16 to 43.38 mm) followed by the flexor digitorum longus tendon at 4.25 ± 1.25 (range 1.74 to 5.95) mm by 2.25 ± 0.96 mm (range 1.41 to 4.79 mm; area 8.88 ± 2.62 mm(2), range 6.12 to 14.52 mm) and flexor hallucis longus tendon at 5.75 ± 2.05 (range 2.27 to 8.91) mm by 2.75 ± 0.82 mm (range 1.35 to 4.13 mm; area 16.81 ± 10.05 mm(2), range 4.81 to 36.80 mm). During dissection for the medial double arthrodesis, one can encounter critical anatomic structures, including artery, vein, nerve, and tendon. Our cadaveric investigation found a mean safe distance of more than 2 cm between the middle facet of the talocalcaneal articulation and the inferiorly located neurovascular bundle using the medial double arthrodesis approach.

A Retrospective Comparison of Cost and Efficiency of the Medial Double and Dual Incision Triple Arthrodeses

While the medial double arthrodesis has gained significant popularity for hindfoot arthrodesis in recent years, much has been touted about the efficiency and cost savings of the procedure in comparison to its triple counterpart without any literature to reinforce this claim. The purpose of this retrospective study was to compare the hardware costs and operative time between the medial double and triple arthrodeses. A total of 276 patients (277 feet) were identified via CPT codes with 47 hindfoot cases (47 feet) meeting the inclusion criteria consisting of 21 medial double (6 males, 15 females) and 26 triple (8 males, 18 females) arthrodeses. No significant difference was noted in age, body mass index, gendr, chronic steroid use, preoperative osteopenia/osteoporosis, tobacco abuse, surgical side, presence of diabetes, immune compromised state, kidney disease, rheumatoid arthritis, or liver disease. Mean medial double operative (OR) time 106 ± 31 minutes (range = 73-201 minutes) with a procedure time of 84 ± 29 minutes (range = 44-163 minutes) was identified versus an OR time of 127 ± 23 minutes (range = 91-200 minutes) and procedure time of 104 ± 23 minutes (range = 50-169 minutes) for the triple arthrodesis group. The mean fixation cost for the triple arthrodesis was found to be higher with the mean triple hardware cost

Screw Placement Relative to the Calcaneal Fracture Constant Fragment: An Anatomic Study

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