Bryan D. Den Hartog

Flexor hallucis longus transfer for chronic Achilles tendonosis.

A technique similar to the one described by Hansen for reconstruction of chronic Achilles tendinosis using the flexor hallucis longus (FHL) tendon was used in 26 patients (29 tendons). Follow-up on all 26 patients (mean age 51.3 years) is provided with an average follow-up 35 months (range, 12 to 58 months). All patients were evaluated postoperatively to assess pain, function, and alignment of the ankle and hindfoot. The AOFAS Foot Ratios for the ankle and hindfoot (total of 100 points) was used. Time to maximum improvement was 8.2 months (range, three to 20 months). Ankle-Hindfoot Scale ratings improved from 41.7 (range, 23 to 63) preoperatively to 90.1 (range, 49 to 100) postoperatively. All but three patients evaluated their result as good or excellent in regards to improved function and pain. No patient had a significant functional deficit or deformity of the hallux after transfer of the FHL tendon.A technique similar to the one described by Hansen for reconstruction of chronic Achilles tendinosis using the flexor hallucis longus (FHL) tendon was used in 26 patients (29 tendons). Follow-up on all 26 patients (mean age 51.3 years) is provided with an average follow-up 35 months (range, 12 to 58 months). All patients were evaluated postoperatively to assess pain, function, and alignment of the ankle and hindfoot. The AOFAS Foot Ratios for the ankle and hindfoot (total of 100 points) was used. Time to maximum improvement was 8.2 months (range, three to 20 months). Ankle-Hindfoot Scale ratings improved from 41.7 (range, 23 to 63) preoperatively to 90.1 (range, 49 to 100) postoperatively. All but three patients evaluated their result as good or excellent in regards to improved function and pain. No patient had a significant functional deficit or deformity of the hallux after transfer of the FHL tendon.

Surgical strategies: delayed diagnosis or neglected achilles' tendon ruptures.

Missed or chronic ruptures of the Achilles tendon present a unique treatment challenge for the treating physician and, if left untreated, can cause significant dysfunction for the patient. What constitutes a delayed or missed diagnosis rupture is not well defined. Different terminology has been used to describe this condition and its treatment, including chronic rupture, neglected rupture, late or old repair, and delayed reconstruction. Dalton6 suggested acute injuries should be defined as being diagnosed and treated at less than 48 hours. Gabel and Manoli10 and Porter et al.20 stated that 4 weeks is the interval cited most often between rupture and repair for the condition to be considered “late.” Myerson19 stated that if treatment is delayed for 6 weeks after rupture, the expected outcome could not parallel the results had the repair been performed more expeditiously, though he thought this depended on the extent of the gap between the tendon ends and the potential for muscle recovery. While there is no definite consensus on when an Achilles tear becomes late or chronic, the end result is a gap between the tendon ends that cannot be apposed by simple plantar flexion of the foot. Filling of this gap requires some form of tissue reconstruction. The most common reason for delayed treatment is delayed diagnosis. However, long-standing tendinosis with micro rupture has been cited as secondary cause for progressive elongation of the tendon resulting in dysfunction.6 Much of the treatment’s success or failure depends on reestablishingMissed or chronic ruptures of the Achilles tendon present a unique treatment challenge for the treating physician and, if left untreated, can cause significant dysfunction for the patient. What constitutes a delayed or missed diagnosis rupture is not well defined. Different terminology has been used to describe this condition and its treatment, including chronic rupture, neglected rupture, late or old repair, and delayed reconstruction. Dalton6 suggested acute injuries should be defined as being diagnosed and treated at less than 48 hours. Gabel and Manoli10 and Porter et al.20 stated that 4 weeks is the interval cited most often between rupture and repair for the condition to be considered “late.” Myerson19 stated that if treatment is delayed for 6 weeks after rupture, the expected outcome could not parallel the results had the repair been performed more expeditiously, though he thought this depended on the extent of the gap between the tendon ends and the potential for muscle recovery. While there is no definite consensus on when an Achilles tear becomes late or chronic, the end result is a gap between the tendon ends that cannot be apposed by simple plantar flexion of the foot. Filling of this gap requires some form of tissue reconstruction. The most common reason for delayed treatment is delayed diagnosis. However, long-standing tendinosis with micro rupture has been cited as secondary cause for progressive elongation of the tendon resulting in dysfunction.6 Much of the treatment’s success or failure depends on reestablishing

Midfoot arthrodesis following multi-joint stabilization with a novel hybrid plating system.

Background: Several methods for fixation have been described for midfoot arthrodesis. Multi-joint arthrodesis at this level can be challenging because of bone loss and deformity, making it difficult to obtain a stable construct. We present the results of a novel hybrid plating system that incorporates locked and non-locked compression screws for multi-joint arthrodesis of the midfoot. Method: A retrospective multicenter review of patients undergoing multi-joint arthrodesis with hybrid plating of the midfoot was performed to evaluate the time to radiographic arthrodesis. Hybrid plating was defined as a construct that incorporates locked and non-locked compression screws. Neuropathy was the only exclusion criteria. Radiographic arthrodesis was defined as bridging bone on one of the three standard foot radiographs in the absence of a joint gap on the other views, or by 50% or greater bridging bone on computed tomography. Etiology of the arthritis, presurgical comorbidities, body mass index, functional level and postoperative complications were evaluated. Results: Seventy-two patients were evaluated, and arthrodesis was obtained in 67 patients at 6 weeks in 27 patients, 9 weeks in 26, 12 weeks in 11, and at 16 weeks in three. In five patients at least one of the joints were not fused at 16 weeks and were considered a nonunion. Complications were present in 12 patients (17%). Conclusions: The healing rate and time to arthrodesis compared favorably to similar published studies. Based on these results, hybrid plating was a reliable and consistent alternative for fixation in midfoot arthrodesis, especially in multi-joint disease. Level of Evidence: IV; Retrospective Case Series

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.

Surgical strategies: acute Achilles rupture-open repair.

The first description of the treatment of acute Achilles tendon rupture is attributed to Ambrose Pare in 1575.13 Prior to the 20th century, Achilles ruptures were treated nonoperatively. In the early 20th century, following the Level IV work of Abrahamsen1 as well as Quenu and Stojanovitch,14 surgical repair of acute Achilles ruptures became more common. It gained further acceptance in the second half of the century with the advent of modern surgical technique and the publication of large clinical series by such authors as Christensen,5 Inglis et al.,7 and Arner and Lindholm.2 Nevertheless, concerns regarding peri-operative complications associated with surgical repair, especially wound problems, led to a resurgence of closed management.12 According to Wills, the overall complication rate for acute Achilles repair between 1959 and 1982 was 20%, most of which were wound-related.16 In 1972, Lea and Smith reported a large series of patients (Level IV evidence), of which 95% enjoyed satisfactory results with cast immobilization despite an 11% re-rupture rate.9 This led others to conclude “it is doubtful whether surgical repair in closed rupture of the Achilles tendon can still be justified.”6 Subsequently, however, reduced complication rates and improved functional outcomes led many surgeons to again advocate surgical repair of acute Achilles ruptures. One notable series was that of Cetti et al.4 In this series, 111 patients were randomized to receive either operative or nonoperative treatment (Level I evidence). The deep infection rate was only 4% in the operative group, compared to a 13% re-rupture rate in the non-operative group. With regard to function, 57% of patients who had surgery were able to return to the same level of sport, compared to 29% of those patients treated non-operatively. In a recent Level IV series of acute Achilles repairs in athletes reported by Mandelbaum et al., there were no re-ruptures and only 2 superficial infections.10

Cadaveric Evaluation of Dorsal Intermetatarsal Approach for Plantar Plate and Lateral Collateral Ligament Repair of the Lesser Metatarsophalangeal Joints

Background: Access to the plantar plate has been described using either a plantar approach or an extensive dorsal approach that required complete joint destabilization and often a metatarsal osteotomy. Clinical scenarios related to plantar plate tear vary and the pathologies in early stages are frequently limited to unilateral soft tissue structures; a less invasive operative approach may be possible. A novel approach requiring a release of only the lateral collateral ligament and the lateral half of the plantar plate is presented in this cadaver model; the extent of joint exposure possible is described. The ability to place a secure suture through the lateral collateral ligament and the plantar plate was analyzed. Methods: Nine fresh-frozen cadaveric specimens were dissected in a randomized fashion across the second to fourth metatarsophalangeal joints through the intermetatarsal space dorsally. Under distraction, soft tissue was sequentially released, including dorsal capsule, lateral collateral ligament, and the lateral half of the plantar plate. Integrity of the extensor tendons, deep transverse intermetatarsal ligament, proximal attachment of the plantar plate, and osseous structures was carefully preserved. The joint exposure was quantified after each step with sizing rods. Using a suture passer, 2-0 nonabsorbable braided sutures were passed into the lateral collateral ligament and the plantar plate, and the construct strength was measured using a tensiometer. Results: Progressive increase in mean joint exposure was noted after each step of soft tissue release with the final exposure of 6 mm after release of the lateral half of the plantar plate. Joint exposures after a capsulotomy and a lateral collateral release were 3 mm and 4 mm, respectively. Under distraction, the unilateral release of soft tissue created a lateral opening of the joint while the proximal phalangeal base adducted and medially deviated. Successful suture passage was noted in all specimens that could sustain a minimum tension of 25 N without a catastrophic failure. There was no statistically significant correlation with age, sex, foot length, and rays of the specimens when joint exposure was considered. Conclusion: The dorsal intermetatarsal approach appeared to be feasible for access to the lateral collateral ligament and the lateral half of the plantar plate. The average joint exposure of 6 mm allowed a quality suture passage by a suture passer in both structures in all specimens without the need of a metatarsal osteotomy. Clinical relevance: This operative approach may be appropriate for early stages plantar plate tear when only lateral soft tissue repair is needed. This technique should not preclude conversion to a more extensile operative approach or an additional metatarsal osteotomy if needed. Applicability of this operative approach in cases with more advanced pathologies or involving only medial soft tissue structures requires further studies.

Minimum 20 Year Follow-Up of Semi-Constrained Total Ankle Arthroplasty: Benchmark for Future Designs

Category: Ankle Arthritis Introduction/Purpose: With the introduction of newer generations of total ankle arthroplasty (TAA) constructs, the incidence of TAA in the United States has been increasing. While TAA has emerged as an alternative to ankle arthrodesis for the management of end-stage ankle arthritis, long-term data evaluating clinical outcomes and the survivorship of ankle prostheses is lacking. The purpose of this study was to report the clinical outcomes and radiographic survivorship of a second-generation, semi-constrained titanium and cobalt-chromium total ankle prosthesis at minimum twenty-year follow-up in order to provide a benchmark comparison for future generations of TAA design. Methods: 132 total ankle replacements in 126 patients were performed by a single surgeon between July 1984 and October 1994. Follow-up evaluation consisted of determining revision status, completion of the validated ankle osteoarthritis scale, a short questionnaire, and a review of the available radiographs. All radiographs were evaluated for evidence of progressive radiolucent lines, osteolysis and component subsidence. Results: At minimum twenty-year follow-up, 37 patients were alive, 89 were deceased, and 5 were lost to follow-up. For living patients, average clinical follow up was 25.3 years. Average radiographic follow-up was 21.4 years. Over the minimum 20 year follow-up, 29 ankles were revised (23%). For living patients, 13 ankles were revised (35%). Conclusion: Twenty-three percent of all patients and 35% of living patients required a revision over the minimum 20 year follow up interval. 65% of living patients have retained their prosthesis and 75% of the entire cohort are still functioning with their original ankle replacement or died with the original ankle replacement in place. This study should provide a benchmark for newer designs when they obtain this length of follow-up.

Effect of Posterior Malleolus Fracture on Syndesmosis Reduction

Category: Trauma Introduction/Purpose: Syndesmotic malreduction and the presence of posterior malleolus fractures negatively influence outcomes in rotational ankle fractures. While there are no universally accepted criteria for posterior malleolar fixation, it has recently been shown that posterior malleolar fixation contributed to the stability of the syndesmosis. However, little is known if and how anatomic or non-anatomic fixation of the posterior malleolus affects syndesmotic reduction. A study analyzing syndesmotic reduction in specimens with varying in size and quality of reduction of the posterior malleolus was conducted. Methods: Nine through-knee cadaveric specimens were randomized into two groups with small (a third of the fibular notch, n=4) and large (two-third of the fibular notch, n=5) posterior malleolar fragments. A model of stage IV supination external rotation injury after fibular repair was created by sharply releasing anterior inferior tibiofibular ligament, superficial and deep deltoid ligaments, and interosseous membrane. Posterior malleolar fracture with predefined sizing was created with preservation of posterior inferior tibiofibular ligament. High resolution CT scan was obtained in each specimen at the four stages; intact, neutral- axis syndesmotic clamping only, with anatomic fixation of the posterior malleolus, and with non-anatomic fixation of the posterior malleolus using a 4.8 mm interposed spacer. Measurement of syndesmotic reduction in both anteroposterior and mediolateral planes was made automatically using a validated technique assisted by custom-developed software at 1 cm proximal to the ankle joint. Results: The presence of either a neutral-axis clamping alone or with an anatomically reduced fracture fragment caused a slight anterior shift of the fibula that was more pronounced in the smaller fragment group. Two-way ANOVA indicated no significant effects of fragment size (p=0.73) or reduction (p=0.09) on AP fibular movement. However, presence of non-anatomical fixation caused the fibula to move significantly posteriorly in the presence of a large posterior malleolar fragment (p=0.03 and p=0.01 relative to the intact and clamping only states). In the mediolateral direction, a neutral-axis clamping alone and clamping with an anatomically reduced fracture fragment both increased medial translation of the distal fibula. The non-anatomic reduction model of the posterior malleolus associated with corresponding lateral displacement of the distal fibula. Conclusion: The overall anteroposterior reduction of the syndesmosis using neutral-axis clamping was generally not affected by posterior malleolar fracture except in a non-anatomic fixation of large fragments. Mediolateral syndesmotic reduction was affected by the conditions of posterior malleolar fixation with best results in anatomic fixation but the intact state was still not replicated. Malreduction of the posterior malleolus led to a corresponding syndesmotic malreduction. When a posterior malleolar fixation is indicated in cases with syndesmotic injury, anatomic fracture fixation is paramount as it can affect syndesmotic reduction especially with larger fragments.

The Dorsal Intermetatarsal Approach for Plantar Plate and Lateral Collateral Ligament Repair of the Lesser Metatarsophalangeal Joints

Category: Lesser Toes Introduction/Purpose: Access to the plantar plate has been described using either a plantar approach or an extensile dorsal approach that required complete joint destabilization and often a metatarsal osteotomy. Clinical scenarios related to plantar plate tear vary and the pathologies in early stages are frequently limited to unilateral soft tissue structures, a more focused surgical approach deemed appropriate. A novel approach requiring a release of only the lateral collateral ligament and the lateral half of the plantar plate was described and the adequacy of joint exposure was evaluated in a cadaver model. The ability to place a suture through the lateral collateral ligament and the plantar plate were analyzed and validated with pull-out strength. Methods: Nine fresh frozen cadaveric specimens were dissected in a randomized fashion across the 2nd to 4th MTP joints through the intermetatarsal space dorsally. Under distraction, soft tissue was sequentially released including dorsal capsule, lateral collateral ligament, and the lateral half of the plantar plate. Integrity of the extensor tendons, deep transverse intermetatarsal ligament, proximal attachment of the plantar plate, and osseous structures was carefully preserved. The joint exposure was quantified after each step with sizing rods. 2/o non-absorbable sutures were passed into the lateral collateral ligament and the plantar plate using a suture passer; and their pullout strength was measured using a tensiometer. Results: Progressive increase in mean of joint exposure was noted after each step of soft tissue release with the final exposure of 6mm after release of the lateral half of the plantar plate. Joint exposures after a capsulotomy and a lateral collateral release were 3mm and 4mm, respectively. Under distraction, the unilateral release of soft tissue created a lateral opening of the joint while the proximal phalangeal base adducted and medially deviated. Successful suture passage was noted in all specimens with mean pullout strength of 76 N for the lateral collateral ligament and 67 N for the plantar plate. There was a statistically significant (p < 0.01) higher suture pullout strength for the lateral collateral ligament in males when compared to female specimens Conclusion: The dorsal intermetatarsal approached appeared to be feasible for the access to the lateral collateral ligament and the lateral half of the plantar plate. The average joint exposure of 6 mm allowed a quality suture passage by a suture passer in both structures in all specimens without the need of a metatarsal osteotomy.

Arthroscopic Plafond Access for Osteochondral Lesions- The Effect of Limited Ankle Range of Motion on Anterior and Posterior Arthroscopic Accessibility

Category: Arthroscopy. Introduction/Purpose: Osteochondral lesions of the tibial plafond (OLTPs) can lead to chronic ankle pain and disability. Arthroscopic treatment has been described after failure of initial nonoperative treatment. However, the ideal appropriate approach for OLTPs is controversial, and it is not known if ankle positioning or joint distraction affects the accessibility of these lesions. The purpose of this study was to determine the effects of predetermined ankle flexion angles on arthroscopic accessibility of the distal tibial articular surface through either the anterior or posterior approach. The effects of non- invasive joint distraction were also analyzed. Methods: Fourteen below-knee cadaver specimens were subjected to pre-operative range of motion measurements. Joint distraction was measured using sizing rods with the precision of 1 mm. The accessible areas at the tibial plafond were marked using a curette at predetermined ankle positions. Arthroscopy was performed using a 30-degree 2.7 mm camera via standard anterior and posterior approaches in randomized fashion in all specimens. Following arthroscopic accessibility, each cadaveric ankle was disarticulated and arthroscopic accessibility was quantified using a surface laser scan. Statistical analyses were performed to determine the correlation between pre-operative ankle range of motion and amount of distraction on arthroscopic accessibility of the tibial plafond. Results: The average accessibility of the tibial plafond was 56 percent and 68 percent for the anterior and posterior approaches, respectively (p = 0.056). There was no difference in accessibility from the anterior approach with increasing level of plantarflexion (p >0.05). Increasing dorsiflexion during the posterior approach significantly reduced ankle accessibility (p = 0.028). There was a significant increase in accessibility through either anterior or posterior approach with increasing level of ankle distraction; (parameter estimates ±SE): anterior= 14.2±3.34, p < 0.01 and posterior= 10.6±3.7, p < 0.05). Conclusion: Arthroscopic accessibility for the treatment of OLTPs was vastly dependent on the amount of intra-operative joint distraction achieved. Posterior approach had more joint distraction and wider plafond accessibility. Increasing ankle distraction significantly improved arthroscopic plafond accessibility for both anterior and posterior approaches while ankle joint position did not influence accessibility from either approach.