Bruce E. Cohen

Associated injuries found in chronic lateral ankle instability.

Sixty-one patients underwent a primary ankle lateral ligament reconstruction for chronic instability between 1989 and 1996. In addition to the ligament reconstruction, all patients had evaluation of the peroneal retinaculum, peroneal tendon inspection by routine opening of the tendon sheath, and ankle joint inspection by arthrotomy. A retrospective review of the clinical history, physical exam, MRI examination, and intraoperative findings was conducted on these 61 patients. The purpose was to determine the type and frequency of associated injuries found at surgery and during the preoperative evaluation. At surgery no patients were found to have isolated lateral ligament injury. Fifteen different associated injuries were noted. The injuries found most often by direct inspection included: peroneal tenosynovitis, 47/61 patients (77%); anterolateral impingement lesion, 41/61 (67%); attenuated peroneal retinaculum, 33/61 (54%); and ankle synovitis, 30/61 (49%). Other less common but significant associated injuries included: intra-articular loose body, 16/61 (26%); peroneus brevis tear, 15/61 (25%); talus osteochondral lesion, 14/61 (23%); medial ankle tendon tenosynovitis, 3/61 (5%). The findings of this study indicate there is a high frequency of associated injuries in patients with chronic lateral ankle instability. Peroneal tendon and retinacular pathology, as well as anterolateral impingement lesions, occur most often. A high index of suspicion for possible associated injuries may result in more consistent outcomes with nonoperative and operative treatment of patients with chronic lateral ankle instability.

Aspiration as a Guide to Sepsis in Revision Total Hip Arthroplasty

One hundred sixty-five patients underwent 171 preoperative aspiration arthrograms to evaluate a painful total hip arthroplasty. Intraoperative cultures and histologic specimens were obtained in all cases. Of the 166 aspirations where fluid was obtained, there were 140 true negative, 5 true positive, 18 false positive, and 3 false negative cultures. Sensitivity of hip aspiration to identify periprosthetic sepsis correctly was 50%; specificity was 88%. Hip aspiration with a 50% sensitivity rate lacks the ability to consistently predict those patients with occult periprosthetic sepsis. The routine use of aspiration in evaluation of a painful total hip is probably not indicated. Selective use in patients with a history of wound healing problems, radiographic changes, and elevated laboratory values should be considered.

Minimally invasive technique versus an extensile lateral approach for intra-articular calcaneal fractures.

Background: The optimal method for treating intra-articular fractures of the calcaneus remains controversial. Extensile approaches allow excellent fracture exposure, but high rates of wound complications are seen. Newer minimally invasive techniques for calcaneus fracture fixation offer a potentially lower wound complication rate, but long-term clinical results are not available. The aim of this study was to compare the outcomes of intra-articular calcaneus fractures treated with open reduction and internal fixation via an extensile approach versus those with a minimally invasive sinus tarsi approach. Methods: We performed a retrospective review of all intra-articular calcaneal fractures treated operatively between October 2005 and December 2008. A total of 112 fractures were found that met our inclusion criteria; 79 were treated with an extensile lateral approach and 33 via a minimally invasive approach based on surgeon preference. Chart and radiographic results were thoroughly reviewed on all 112 fractures, specifically for wound healing complications and the need for further surgeries within the study period. Additionally, all patients were contacted and asked to return for a research visit that included radiography, clinical examination, and quality of life questionnaires (Short Form 36 [SF-36], foot function index [FFI], visual analog scale [VAS] pain). A total of 47 of 112 (42%) patients returned for a research visit (31 extensile, 16 minimally invasive). Results: The 2 groups were comparable with regard to demographics (age, follow-up, male to female ratio, tobacco use, diabetes, workers’ compensation status). In the extensile group, 53% of fractures were Sanders II and 47% were Sanders III, whereas in the minimally invasive group 61% were Sanders II and 39% were Sanders III. The overall wound complication rate was 29% in the extensile group (9% required operative intervention) versus 6% in the minimally invasive group (P = .005) (none required operative intervention). Overall, 20% of the extensile group required a secondary surgery within the study period versus 2% in the minimally invasive group (P = .007). In the group of patients who returned for research visits, the average FFI total score was 31 in the extensile group versus 22 in the minimally invasive group (P = .21). The average VAS pain score with activity was 36 in the extensile group versus 31 in the minimally invasive group (P = .48). Overall, 84% of patients in the extensile group were satisfied with their result versus 94% in the minimally invasive group (P = .32). Both groups had 100% union rates, and no differences were noted in the final postoperative Bohler’s angle and angle of Gissane. Conclusion: Clinical results were similar between calcaneal fractures treated with an extensile approach and those treated with a minimally invasive approach. However, the minimally invasive approach had a significantly lower incidence of wound complications and secondary surgeries. The minimally invasive approach was a valuable method for the treatment of intra-articular calcaneal fractures, with low complication rates and results comparable to those treated with an extensile approach. Level of Evidence: Level III, retrospective comparative case series.

Subtalar Arthrodesis with Flexor Digitorum Longus Transfer and Spring Ligament Repair for Treatment of Posterior Tibial Tendon Insufficiency

The surgical treatment of flexible pes planovalgus deformities resulting from Stage 2 posterior tibial tendon insufficiency is controversial and many techniques have been proposed. We retrospectively reviewed the results of subtalar arthrodesis combined with spring ligament repair/reefing and flexor digitorum longus (FDL) transfer to the navicular. There were sixteen patients (seventeen feet) with an average follow-up of 27 months (9–52). All deformities were passively correctable. The average age was 56 yrs (39–78). All patients had failed conservative management, 88% had previously been treated with orthotics, and 53% had lateral pain from subfibular impingement. Two patients were noted to have degenerative changes of the subtalar joint. Successful subtalar joint fusion occurred in all patients with an average time to radiographic union of 10.1 weeks (5–24). The average AOFAS hindfoot score and Maryland foot score postoperatively was 82 and 86 respectively. Standing radiographic analysis demonstrated an average improvement in the AP talo-1st metatarsal angle of 6° (24° preoperative, 18° postoperative). The talonavicular coverage angle improved an average of 17° (34° preoperative, 17° postoperative). The lateral talo-1st metatarsal angle improved an average of 10° (18° preoperative, 8° postoperative). The lateral talocalcaneal angle decreased an average of 21 o (55° preoperative, 34° postoperative). The distance of the medial cuneiform to the floor on the lateral radiograph averaged 12mm preoperatively and 18mm postoperatively (avg. improvement 6mm). The combination of the flexor digitorum longus tendon transfer and spring ligament repair with subtalar arthrodesis is an effective and reliable procedure which provides excellent correction of hindfoot valgus as well as forefoot abduction and restoration of the height of the longitudinal arch. These results compare favorably with flexor transfer combined with either calcaneal osteotomy or lateral column lengthening.

Review of 107 Hallux MTP Joint Arthrodesis Using Dome-Shaped Reamers and a Stainless-Steel Dorsal Plate

Background: The purpose of this study was to retrospectively review the results of patients treated with hallux MTP joint arthrodesis using dome-shaped reamers for joint preparation and a precontoured dorsal stainless steel plate for internal fixation. Materials and Methods: A series of 145 patients (155 feet) were identified. Postoperative evaluation included weightbearing radiographs, physical examination, and chart review. Outcomes were assessed with a pain visual analog scale, AOFAS hallux score, as well as a detailed questionnaire and a subjective satisfaction survey. Results: 98 patients (107 feet) met the criteria for the study. The mean followup was 61 weeks. Revision cases accounted for 18.7% (20/107). Rheumatoid arthritis (RA) was present in 32.7% (35/107). The average postoperative AOFAS hallux score was 79.7 and pain VAS was 19. The average pre and postoperative hallux valgus angle was 26.5 and 12.3 degrees, respectively (p < 0.05). Eighty-nine of 107 patients (83.1%) reported good to excellent results at final followup. Discomfort related to prominence of the plate occurred in 14.9% (16/107). The nonunion rate was 12.1% (13/107). The nonunion rate for patients with/without RA was 22.9% (8/35) and 6.9% (5/72), respectively (p < 0.05). Patients with a nonunion noted more hardware related pain than those with a union (p < 0.05). Conclusion: First MTP joint arthrodesis using this technique achieves a high union rate. RA patients have a lower union and higher complication rate. Level of Evidence: IV, Retrospective Case Series

Evaluation of the hallux morbidity of single-incision flexor hallucis longus tendon transfer.

Background: Achilles tendinosis and chronic Achilles tendon ruptures are relatively frequently encountered by orthopaedic surgeons. One treatment for patients who fail to respond to conservative management involves augmentation of the repair with transfer of the flexor hallucis longus (FHL), using either a single-incision or double-incision technique. Despite the frequency of this procedure, little is known about the associated donor morbidity. We report the effects of the single-incision technique on hallux function. Materials and Methods: We retrospectively reviewed 48 patients who underwent a single-incision FHL tendon transfer for chronic Achilles tendon rupture or Achilles tendinosis. Twenty-two patients (mean followup, 28 months) completed the study. The average age was 56 years. Outcome measures included the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal (MTP) joint and interphalangeal (IP) joint scores, the Health Related Quality of Life Measures Short Form (SF-36). Also, the average of two pedobarographic measurements of both feet and strength testing of the FHL of both feet were recorded. Results: Decreased distal phalangeal pressure and FHL weakness were demonstrated (p < 0.05). No difference was noted in plantar pressure of the first or second metatarsal head. The high score on the AOFAS hallux MTP-IP scale demonstrated improved patient forefoot function after FHL transfer through a single-incision technique. Conclusion: Flexor hallucis longus tendon transfer using a single-incision technique results in decreased flexion power at the IP joint as demonstrated by decreased distal phalangeal pulp pressure; however, this appears to be a laboratory finding as patient function remains high. Level of Evidence: IV, Retrospective Case Series

Success of Calcaneonavicular Coalition Resection in the Adult Population

Twelve adult patients (13 feet), average age 33 years (range, 19–48 years), with calcaneonavicular coalitions remained symptomatic after a trial of conservative treatment. Surgical resections were performed. Before surgery, there was <5° of inversion/eversion in 11 patients, radiographic evidence of degenerative arthritis in 10 feet (77%), and talar beaking in 7 feet. At an average postoperative follow-up of 36 months, subjective relief of preoperative symptoms was achieved in all but two patients. Two patients required subsequent hindfoot arthrodesis. Resection of calcaneonavicular coalition in the adult can be successful and provides an option to arthrodesis after nonoperative methods have failed.

Hallux Sesamoid Disorders

Sesamoid disorders are common causes of forefoot pain. Because of the significant mechanical stresses and anatomic variations involved, the sesamoid complex appears to be affected by numerous pathologic processes. These include acute fractures, stress fractures, nonunions, osteonecrosis, chondromalacia, and various inflammatory conditions labeled sesamoiditis. Treatment options include conservative management with orthotics and immobilization, as well as operative interventions that range from fracture/nonunion fixation to various approaches for sesamoidectomy. This article outlines the diagnosis and treatment of these entities and reviews the results of these treatments.

Locked versus Nonlocked Plate Fixation for Hallux MTP Arthrodesis

Background: Dorsal plate fixation is used commonly for arthrodesis of the hallux first metatarsophalangeal (MTP) joint. Custom dorsal plates incorporating locking technology have been developed recently for applications in the foot to provide relative ease of application and theoretically superior mechanical properties. The purpose of this study is to compare the radiographic and clinical outcomes of patients undergoing hallux MTP joint arthrodesis using a locked plate, or a nonlocked plate. Materials and Methods: We compared consecutive patients who underwent hallux MTP arthrodesis for a variety of diagnoses with either a precontoured locked titanium dorsal plate (Group 1) or a precontoured, nonlocked stainless steel plate (Group 2). All patients were evaluated with radiographs, visual analog pain scale, American Orthopaedic Foot and Ankle Society (AOFAS) hallux score, and a detailed patient satisfaction survey. Results: There were 73 feet in Group 1 and 107 feet in Group 2. There was a trend toward a higher nonunion rate in Group 1 compared to Group 2. When considering only patients without rheumatoid arthritis (RA), the union rate was significantly higher in Group 2 compared to Group 1. Hardware failure and the overall complication rate was equivalent between the two Groups. Conclusion: As locked plate technology continues to gain popularity for procedures in the foot, it is important that clinical outcomes are reported. Locked titanium plates were associated with higher nonunion rates. Improved plate design, patient selection, and an understanding of plate biomechanics in this unique loading environment may optimize future outcomes for hallux MTP arthrodesis. Level of Evidence: III, Retrospective Comparative Study

Clinical Outcomes and Complications of Percutaneous Achilles Repair System Versus Open Technique for Acute Achilles Tendon Ruptures

Background: Limited incision techniques for acute Achilles tendon ruptures have been developed in recent years to improve recovery and reduce postoperative complications compared with traditional open repair. The purpose of this retrospective cohort study was to analyze the clinical outcomes and postoperative complications between acute Achilles tendon ruptures treated using a percutaneous Achilles repair system (PARS [Arthrex, Inc, Naples, FL]) versus open repair and evaluate the overall outcomes for operatively treated Achilles ruptures. Methods: Between 2005 and 2014, 270 consecutive cases of operatively treated acute Achilles tendon ruptures were reviewed (101 PARS, 169 open). Patients with Achilles tendinopathy, insertional ruptures, chronic tears, or less than 3-month follow-up were excluded. Operative treatment consisted of a percutaneous technique (PARS) using a 2-cm transverse incision with FiberWire (Arthrex, Inc, Naples, FL) sutures or open repair using a 5- to 8-cm posteromedial incision with FiberWire in a Krackow fashion reinforced with absorbable sutures. Patient demographics were recorded along with medical comorbidities, activity at injury, time from injury to surgery, length of follow-up, return to baseline activities by 5 months, and postoperative complications. Results: The most common activity during injury for both groups was basketball (PARS: 39%, open: 47%). A greater number of patients treated with PARS were able to return to baseline physical activities by 5 months compared with the open group (PARS: 98%, open: 82%; P = .0001). There were no significant differences (P > .05) between groups in rates of rerupture (P = 1.0), sural neuritis (P = .16), wound dehiscence (P = .74), superficial (P = .29) and/or deep infection (P = .29), or reoperation (P = .13). There were no deep vein thromboses (DVTs) or reruptures in either group. In the PARS group, there were no cases of sural neuritis, 3 cases (3%) of superficial wound dehiscence, and 2 reoperations (2%) for superficial foreign-body reaction to FiberWire. In the open group, there were 5 cases (3%) of sural neuritis, 7 cases (4%) of superficial wound dehiscence, 3 cases (2%) of superficial infection, and 3 reoperations (2%) for deep infection. Conclusion: The present study reports the largest single-center series of acute Achilles tendon ruptures in the literature with lower complication rates for operatively treated Achilles ruptures compared with previous reports. The overall complication rate for all operatively treated Achilles ruptures was 8.5% with no reruptures, and most patients (88%) were able to return to baseline activities by 5 months after surgery. There were no significant differences in rates of postoperative complications between PARS and open repair for acute Achilles tendon ruptures. Level of Evidence: Level III, retrospective cohort study.