Brent Cone

Results of lateral ankle ligament repair surgery in one hundred and nineteen patients: do surgical method and arthroscopy timing matter?

PurposeAnkle sprains are the most common athletic injury. One of five chronic lateral ankle instability patients will require surgery, making operative outcomes crucial. The purpose of this study is to determine if operative method influences failure and complication rates in chronic lateral ankle ligament repair surgery.MethodsWe retrospectively reviewed 119 cases (118 patients) of lateral ankle ligament surgery between 2006 and 2016. Patient charts and operative reports were examined for demographics, use and timing of ankle arthroscopy, ligament fixation method, type of surgical incision, presence of calcaneofibular ligament repair, and operative technique. Impact of operative methods on failure (one-year minimum follow-up) and complication outcomes was explored using Chi-square test of independence (or Fisher’s exact test). Statistical significance was set at p less than .05.ResultsMean age at surgery was 40 (range, 18-73) years. Mean follow-up was 51 (range, 12-260) weeks. Failure rate was 8.4% (10/89 cases) while complication rate was 17.6% (21/119). Failure rate did not differ significantly between any data subgroups (pxa0>xa0.05). Single stage arthroscopy was associated with a significantly lower complication rate (11%, 4/37) than double-stage arthroscopy (47%, 9/19) (pxa0<xa0.01) as was suture anchor ligament fixation (9%, 6/67) compared to direct suture ligament fixation (29%, 15/52) (pxa0<xa0.01).ConclusionFailure rate was not impacted by any of the studied variables. Use of suture anchors and concurrent ankle arthroscopy may be favourable options to achieve fewer complications in chronic lateral ankle instability repair surgery.

The success rate of First Metatarsophalangeal Joint Lateral Soft Tissue Release through a Medial Transarticular Approach: A Cadaveric Study

BACKGROUNDnThe objective of this study was to evaluate the success rate of first metatarsophalangeal joint (MTPJ) lateral soft tissue release through a medial transarticular approach.nnnMETHODSnTen cadaveric specimens were used (6 females/4 males, mean age, 73.4years). Lateral release was performed through a 4cm medial approach using a number 15 blade. Surgical aim was to release four specific structures: lateral capsule, lateral collateral ligament (LCL), adductor hallucis tendon (AHT) and lateral metatarsosesamoid suspensory ligament (LMSL). Once completed, a dissection of the first intermetatarsal space was performed. Success rate was graded in accordance to the number of structures successfully released: 0% (no structures), 25% (1/4), 50% (2/4), 75% (3/4) and 100% (4/4). Inadvertent injuries to other soft tissue structures were recorded.nnnRESULTSnThe success rate for lateral soft tissue release was 100% in 7 cadaveric specimens, and respectively 75%, 50% and 25% in the other 3 specimens. The LCL was successfully released in all specimens. The lateral joint capsule, AHT and LMSL were released in 80% of the specimens. Chondral damage to the first metatarsal head, unintended release of the conjoined tendon and lateral head of the flexor hallucis brevis (FHB) occurred respectively in 40%, 50% and 20% of the specimens.nnnCONCLUSIONSnOur cadaveric study demonstrated high success rate in the release of specific lateral soft tissue structures of the first MTPJ through a medial transarticular approach. Inadvertent release of the lateral head of the FHB, conjoined tendon and iatrogenic chondral damage of the first metatarsal head are complications to be considered.nnnLEVEL OF EVIDENCEnCadaveric study - Level V.

Radiographic Evaluation of First MTP Joint Arthrodesis For Severe Hallux Valgus: Does the introduction of a lag screw improve union rates and correction of the intermetatarsal angle?

BACKGROUNDnFirst metatarsophalangeal (MTP-1) joint fusion is a reliable method for the correction of various deformities including hallux valgus and hallux rigidus. Ideal constructs provide high rates of fusion in desired alignment. The present study examines the union rates, as well as the change in dorsiflexion angle during the follow up period in patients who underwent MTP-1 fusion with a dorsal locking plate and a lag screw, versus patients fused with a dorsal locking plate alone.nnnMETHODSnThis is a retrospective review of 99 feet undergoing MTP-1 fusion. Joints were fused using either a dorsal locking plate alone or a lag screw plus a dorsal locking plate. Union was determined radiographically during the follow up period. Suspected nonunions were confirmed with CT. Dorsiflexion angles were radiographically measured at first post-operative visit and at final follow up.nnnRESULTSnThere were 36 patients in the lag screw plus dorsal plate group, and 63 in the dorsal plate group. Mean follow up was 12.9 months (Range: 12-33.5 months). The dorsal plate plus lag screw group had a significantly lower change in mean dorsiflexion angle (0.57°±5.01°) during the post-operative period compared to the dorsal plate group at final follow up versus the dorsal plate group (6.73°±7.07°).nnnCONCLUSIONnThe addition of a lag screw to a dorsal locking plate for MTP-1 arthrodesis may offer improved stability of the joint in the sagittal plane over time compared to a dorsal plate alone.nnnLEVEL OF EVIDENCEnRetrospective level III evidence.

First Metatarsophalangeal Joint Arthrodesis: Does the Addition of a Lag Screw to a Dorsal Locking Plate Influence Union Rate and/or Final Alignment after Fusion

&NA; First metatarsophalangeal (MTP‐1) joint fusion is a reliable method for the correction of various deformities, including hallux valgus and hallux rigidus. Ideal constructs provide high rates of fusion in the desired alignment. The present study examined the union rates and the change in dorsiflexion angle during the follow‐up period in patients who had undergone MTP‐1 fusion with a dorsal locking plate and a lag screw compared with patients who had undergone fusion with a dorsal locking plate alone. We performed a retrospective review of 99 feet undergoing MTP‐1 fusion. The joints were fused using either a dorsal locking plate alone or a lag screw plus a dorsal locking plate. Union was determined radiographically during the follow‐up period. Suspected nonunions were confirmed by computed tomography. The dorsiflexion angles were radiographically measured at the first postoperative visit and at the final follow‐up visit. Of the 99 feet, 36 (36.4%) were in the lag screw plus dorsal plate group and 63 (63.6%) in the dorsal plate group. The mean follow‐up period was 12.9 (range 12 to 33.5) months. The dorsal plate plus lag screw group had a significantly lower change in the mean dorsiflexion angle (0.57° ± 5.01°) during the postoperative period compared with the dorsal plate group (6.73° ± 7.07°). The addition of a lag screw to a dorsal locking plate for MTP‐1 arthrodesis might offer improved stability of the joint in the sagittal plane over time compared with a dorsal plate alone. &NA; Level of Clinical Evidence: 3

A comparison of union rates and complications between single screw and double screw fixation of sliding calcaneal osteotomy

BACKGROUNDnThe number of screws used for sliding calcaneal osteotomy fixation has not been examined in the literature. The purpose of this paper is to examine this topic.nnnMETHODSnRetrospective chart review was performed on 190 patients who met selection criteria. We compared complication risk for single versus double screw, headed versus headless screw, and short versus longitudinal incision cases.nnnRESULTSnThe mean age was 48.4 (18-83) years and average follow up was 28 (12-150) weeks. All cases achieved radiographic union. Overall complication rate was 19.5% (37/190). Risk of complication did not differ significantly between single and double screw (RR: 1.170; 95% CI: 0.66-2.09; p=0.594) or short and extended incision groups (RR: 0.868; 95% CI: 0.42-1.80; p=0.704). Risk of complication differed significantly between headed and headless screw fixation (RR: 5.558; 95% CI: 2.69-11.50; p<0.0001).nnnCONCLUSIONSnSingle screw fixation of sliding calcaneal osteotomy achieves similar outcomes as double screw fixation. Headless screws are advantageous for minimizing hardware pain and subsequent hardware removal.

Outcomes of First Metatarsophalangeal Joint Fusion in Patients with Greater Than Fifteen Percent Intermetatarsal Angle. Is Lag Screw Essential

Category: Midfoot/Forefoot Introduction/Purpose: Metatarsophalangeal arthrodesis has usually been performed using a dorsal plate to immobilize the MTP joint with or without lag screw fixation. Data in the literature is sparse on outcomes of dorsal plate plus lag screw fixation, especially in patients with IMA greater than 15 percent. Our objective was to compare IMA correction outcomes and union rates between dorsal plate only fusions and dorsal plate plus lag screw fixation in patients with IMA greater than 15 percent. Methods: We retrospectively reviewed the charts of 36 patients (39 feet) who underwent first MTP joint arthrodesis for moderate to severe HV deformity between 2011 and 2015. Average age was 61 (range, 39 to 84) years. There were 24 females and 12 males. A single surgeon performed all operations. Joints were immobilized postoperatively using either dorsal locking plate alone or dorsal locking plate with a lag screw. Union (at least 3 bridging cortices) was determined radiographically at 6 weeks, 3 months, 6 months and yearly. All suspect nonunions were examined with CT. Other radiographic parameters examined included preoperative and postoperative hallux valgus, intermetatarsal, and dorsiflexion angles (HVA, IMA, and DFA respectively). Student’s t test was used to compare group means while Pearson’s Chi square test was used to compare group rates. Results: Overall union rate was 82.1% (32/39). There was no significant difference in union rates between the two groups (dorsal plate only = 81.5% (22/27), dorsal plate plus lag screw group = 83.3% (10/12)) (P > 0.05). Average follow-up was 9 (range 7 to 35) months. Overall, the average IMA correction was 4.7 (preoperative = 17.8, postoperative = 13.1) degrees. Average IMA corrections were 4.7 and 4.54 degrees in the dorsal plate only group and dorsal plate plus lag screw groups respectively. Overall, average HVA correction was 21 (preoperative = 39.5, postoperative = 18.5) degrees. Conclusion: Our findings indicate that there is no difference in the fusion rates between both patient groups with IMA greater than fifteen percent. Because other published studies have a wide range of IMAs preoperatively, our study represents more attainable goals in patients with severe (IMA greater than 15%) deformities. In addition, our findings suggest that in such patients, MTP arthrodesis may not be sufficient as a standalone procedure for correction of IMA. Additional proximal osteotomy may be required for correction of the IMA.

Calcaneal Osteotomies in the treatment of Hindfoot Deformities: Comparison between One Screw vs Two Screws fixation technique

Category: Hindfoot Introduction/Purpose: Calcaneal osteotomy is a common procedure for hindfoot deformities correction. Screw fixation is the most common technique used to stabilize these osteotomies. The clinical decision regarding the number of screws used is frequently based on the surgeon’s experience without sufficient data regarding outcomes and complications. The aim of this study was to compare the outcomes and complications of one versus two screws fixation technique of sliding calcaneal osteotomies. Methods: We reviewed 190 patients (112 female, 78 male) who underwent corrective calcaneal osteotomy for hind-foot angular deformity between 2010-2016. The average age was 48.4 years (18-83), and mean follow-up was 28 weeks (4-150). We divided patients into two groups, according to the number of screws used in the osteotomy fixation (one or two). 85 osteotomies were fixed by one screw and 105 by two screws. We compared both groups regarding incision type, positioning and type of the screws (headed or headless) and complications (non-union, infection, hardware related heel pain). Results: The average time for radiographic union was similar between the groups, around 5.6 weeks (4-10 weeks). Non-unions were not found. The overall Incidence of complications was not significant different in the one screw group compare two screw group (12.7% x 8%, p-value 0.465). Infection rate was similar in both groups (4.7% vs 3.5%, p-value 0.674). There was not significant difference of hardware related heel pain between two groups (15.2% vs 8.5%, p-value 0.149). Similarly, no difference in incidence of hardware related symptoms between patients who used headed screw when comparing with headless screws. Conclusion: Our study compared results in the use of one screw versus two screws fixation technique for sliding calcaneal osteotomies. We found similar time for union. Base of date there was no significant difference of complications, infection, and hardware related heel pain between patients who used one screw when comparing two screws fixation technique for corrective calcaneal osteotomy.

Effectiveness of Lateral Soft Tissue Release of the 1st Metatarsophalangeal Joint Through a Medial Transarticular Approach – A Cadaver Study

Category: Bunion Introduction/Purpose: First metatarsophalangeal joint lateral soft tissue release is frequently performed during corrective surgery for hallux valgus deformity. Surgical approaches include an open dorsal approach as well as a medial transarticular approach. The medial transarticular approach avoids the need for a second incision while also attenuating the risk of avascular necrosis of the first metatarsal head. However, this method is limited by the poor visualization of the lateral structures through the joint. The objective of this study was to evaluate the effectiveness of the medial transarticular approach for lateral soft tissue release in the 1st metatarsophalangeal joint. Methods: Ten below-the-knee fresh-frozen cadaveric specimens were used (6 females, 4 males). The mean age was 73.4 years. Two specimens had moderate hallux valgus deformity. None of the samples had considerable degenerative changes of the first metatarsophalangeal joint. Lateral soft tissue release was performed using a single 2.5 cm medial incision. Lateral soft tissue release targeted the lateral collateral ligament, lateral capsule, adductor hallucis muscle tendon and lateral metatarsosesamoid suspensory ligament. A single surgeon performed all procedures. An extended lateral dissection of the 1st intermetatarsal space was carried out to examine the accuracy of the technique. Successful release of each targeted structure (4 total) was recorded for each specimen. Thus, the percentage of successful release was computed for each specimen. Injuries to important non-targeted structures were also registered. Results: All four targeted structures were successfully released (100%) in seven of the ten cadavers. Three out of four structures were released (75%) in one cadaver, while two of the four and one of the four targeted structures were successfully released in the other two cadavers (50% and 25% success respectively). Lateral collateral ligament was successfully released in all cadavers. Lateral joint capsule, adductor hallucis muscle tendon, and lateral metatarsosesamoid suspensory ligament were released in 80% of the specimens. 1st metatarsal head chondral and unintended release of lateral head of the flexor hallucis brevis occurred respectively in 40% and 50% of the procedures. No injuries to the flexor hallucis longus tendon, neurovascular bundle, deep transverse metatarsal ligament or chondral damage to the proximal phalanx were recorded. Conclusion: Lateral soft tissue release of the first metatarsophalangeal joint can be successfully performed through a medial transarticular approach. Inadvertent release of the lateral head of the flexor hallux brevis and chondral damage of the 1st metatarsal head are complications to be considered.

Lateral Ankle Instability Surgical Treatment: A Comparison Between Primary Repair and Revision Surgery

Category: Ankle, Sports Introduction/Purpose: Lateral ankle instability is a common cause of disability in the active population. Although the majority of patients can be treated conservatively, surgical repair of the ligaments, with or without reinforcement, represents an excellent option for refractory cases. Failed primary surgical repair, recurrence of the ankle instability and need for revision surgery can rarely happen and is probably affected by multiple variables. That includes patient’s characteristics such as BMI and comorbidities and surgical aspects such as the use of suture anchors and soft-tissue reinforcement. The purpose of this study was to compare patient’s characteristics and complication rates of primary repair and revision procedures. Methods: We retrospectively reviewed 231 patients (160 Female, 71 Male) who underwent surgical treatment for lateral ankle instability between 2010-2016. Thirty-two were revision cases (14.2%), including 24 females and 8 males, and 199 were primary direct repairs (85.8%). The mean age at the time of the surgery was 39 (19-65)years, and average follow-up was 9 (2-55) months. The procedures were performed by four different surgeons. All cases were reviewed based on age, gender, BMI, procedure type and number of incisions, comorbidities, and complications. Data found was compared between the two groups (primary repair and revision surgery) by T-test. A p-value <0.05 was considered significant. Results: The Brostrom-Gould procedure was used in 69.5% of the primary repairs and 63.6% of the revision cases. The use of suture anchors was also similar in both groups (51%). Repair of the calcaneofibular ligament was performed in 68% of primary repairs and 81.8% of the revisions. We didn’t find significant differences regarding comorbidities between two groups: smoking (23.4% x 27.2%, p-value 0.371); diabetes (6.8% x 6%, p-value 0.951) and body mass index above 30 (28.5% x 24.2%, p-value 0.347). We found significant difference in the complication rate of the procedures, with a higher incidence in the revision group (48.4%) when compared to the primary repair group (24%). That included: sural neuritis (15.1% x 3.4%), superficial peroneal neuritis (12.1% x 4.5%), skin problems (9% x 7.4%). Conclusion: Our study of 231 patients that underwent surgical treatment for lateral ankle instability found significant higher incidence of complications in patients who had revision procedures when compared to primary repair. No differences regarding smoking status, diabetes and BMI were found.

Revisiting the Prevalence of Associated Co-Pathologies in Chronic Lateral Ankle Instability

Category: Ankle, Hindfoot, Sports Introduction/Purpose: Ankle sprains are the most common athletic injury with an estimated 30% risk of developing chronic lateral ankle instability. Up to 20% of these patients will require surgical management after trial of conservative treatment for chronic disease. Current literature suggests that the presence and type of co-pathologies associated with chronic lateral ankle instability can serve as important predictors of surgical outcomes. As the occurrence of these co-pathologies varies in the literature, providers may underestimate their presence which may lead to suboptimal surgical approach. The purpose of this study is to re-examine the prevalence of common associated lesions in patients who underwent surgical treatment for chronic lateral ankle instability. Methods: We retrospectively reviewed medical charts for 389 cases of lateral ankle instability repair surgery at our institution between June 2006 and November 2016. All patients had undergone at least 6 months of conservative therapy such as ankle stabilizing orthosis or physical therapy with no improvement. All operations were performed by senior orthopaedic surgeons. Exclusion criteria included age less than 18 at time of surgery, gross traumatic event, and history of ipsilateral subtalar arthrodesis. Demographic information such as age, gender, body mass index, and race/ethnicity were collected. 166 surgical notes accessible through the electronic medical record were reviewed for specific intra-operative findings including presence of peroneal pathology (including tendon split lesion), talar osteochondral defects, anterior or posterior ankle impingement, low lying muscle belly of the peroneus brevis and surgical approach. Simple descriptive statistics were used to examine means and frequencies of the collected data. Results: 166 cases (48 males, 118 females) were included (mean age = 39 ±13.4 years, mean body mass index = 31.41 ± 7.5 kg/m2, mean follow-up = 44 ± 46 weeks). 95 cases involved the left foot while 71 cases involved the right foot. Two senior surgeons accounted for 87% (145/166) of the cases. 20 cases were revisions. 72.3% (120/166) of all cases had associated peroneal pathology (36.6% (44/120) peroneus brevis split lesion and 5.8% (7/120) with peroneus longus split lesion). 41% (69/166) of the patients had ankle impingement (anterior = 32; posterior = 19. combined = 17), 37% (62/166) had a low lying muscle belly of the peroneus brevis and 19% (32/166) had osteochondral lesions of the talus. Conclusion: Surgical approach and long-term outcomes can be affected by the knowledge and proper diagnosis of chronic lateral ankle instability associated lesions. Our study reinforces the need for vigilant exploration of chronic ankle instability patients who require surgical treatment. More specifically, surgical exploration for peroneal pathology and ankle impingement may be crucial as our findings reveal a high intraoperative rate of their occurrence. While the role of a low-lying peroneus brevis muscle belly in the development or course of chronic lateral ankle instability remains to be elucidated, we report a significant percentage of its occurrence.