C. Senthil Kumar

Long-term Results of the Modified Hoffman Procedure in the Rheumatoid Forefoot: Surgical Technique

BACKGROUND Rheumatoid arthritis commonly affects the forefoot, causing metatarsalgia, hallux valgus, and deformities of the lesser toes. Various types of surgical correction have been described, including resection of the lesser-toe metatarsal heads coupled with arthrodesis of the great toe, resection arthroplasty of the proximal phalanx or metatarsal head, and metatarsal osteotomy. We report the results at an average of five and a half years following thirty-seven consecutive forefoot arthroplasties performed in twenty patients by one surgeon using a technique involving resection of all five metatarsal heads. METHODS All patients were treated with the same technique of resection of all five metatarsal heads through three dorsal incisions. All surviving patients were asked to return for follow-up, which included subjective assessment (with use of visual analogue pain scores, AOFAS [American Orthopaedic Foot and Ankle Society] foot scores, and SF-12 [Short Form-12] mental and physical disability scores), physical examination, and radiographic evaluation. RESULTS All results were satisfactory to excellent in the short term (six weeks postoperatively), and no patient sought additional surgical treatment for the feet. A superficial infection subsequently developed in two feet, and two feet had delayed wound-healing. At an average of 64.9 months postoperatively, the average AOFAS forefoot score was 64.5 points and the average hallux valgus angle was 22.3 degrees. There were no reoperations. CONCLUSIONS Resection of all five metatarsal heads in patients with metatarsalgia and hallux valgus associated with rheumatoid arthritis can be a safe procedure that provides reasonable, if rarely complete, relief of symptoms.

Long-Term Results of the Modified Hoffman Procedure in the Rheumatoid Forefoot

BACKGROUND Rheumatoid arthritis commonly affects the forefoot, causing metatarsalgia, hallux valgus, and deformities of the lesser toes. Various types of surgical correction have been described, including resection of the lesser-toe metatarsal heads coupled with arthrodesis of the great toe, resection arthroplasty of the proximal phalanx or metatarsal head, and metatarsal osteotomy. We report the results at an average of five and a half years following thirty-seven consecutive forefoot arthroplasties performed in twenty patients by one surgeon using a technique involving resection of all five metatarsal heads. METHODS All patients were treated with the same technique of resection of all five metatarsal heads through three dorsal incisions. All surviving patients were asked to return for follow-up, which included subjective assessment (with use of visual analogue pain scores, AOFAS [American Orthopaedic Foot and Ankle Society] foot scores, and SF-12 [Short Form-12] mental and physical disability scores), physical examination, and radiographic evaluation. RESULTS All results were satisfactory to excellent in the short term (six weeks postoperatively), and no patient sought additional surgical treatment for the feet. A superficial infection subsequently developed in two feet, and two feet had delayed wound-healing. At an average of 64.9 months postoperatively, the average AOFAS forefoot score was 64.5 points and the average hallux valgus angle was 22.3 degrees . There were no reoperations. CONCLUSIONS Resection of all five metatarsal heads in patients with metatarsalgia and hallux valgus associated with rheumatoid arthritis can be a safe procedure that provides reasonable, if rarely complete, relief of symptoms.

Mid-term Results of the MOJE Hallux MP Joint Replacement

Background: There are reports of good early results in small numbers of patients implanted with the ‘Moje’ ceramic prosthesis. Published evidence thus far involves only small groups of patients with short-term followup. The purpose of this prospective study was to evaluate the emerging mid-term clinical and radiographic results from our center. Materials and Methods: We describe our single-surgeon experience of 63 components in 48 patients at a mean followup of 44 months. Patient satisfaction was assessed by questionnaire and radiographic assessment performed immediately post operatively and at the latest followup. Results: Mean American Orthopaedic Foot and Ankle Society (AOFAS) Hallux score increased from 56 to 72 (p >0.01) and mean satisfaction score was 7.6 (scale 1–10). Sixty-seven percent reported minimal or no pain. Five implants have been removed (8%), four because of pain associated with implant loosening and subsidence, and one because of deep infection. Fifty-seven percent of metatarsal and 56% of phalangeal components had subsided and we found radiographic evidence of loosening in 58% of X-rays analyzed at latest followup. Prosthetic subsidence was associated with greater margin of uncovered bone under the prosthesis (p = 0.05 for metatarsal, p = 0.03 for proximal phalanx component) and longer followup (p >0.001). Conclusion: In spite of the good clinical outcome at the mid-term stage with 91% implant survival, given the widespread loosening and subsidence encountered in our study, the long-term outcome following this procedure is uncertain. Level of Evidence: III, Prospective, Case Control Study

Nerve blocks in foot and ankle surgery

A prospective study was conducted to evaluate the efficacy of nerve blocks for postoperative pain relief following foot and ankle surgery. The study included all patients who underwent foot and ankle surgery over a period of three months. Sciatic/popliteal nerve blocks were administered for hindfoot surgery and ankle blocks for forefoot surgery. Postoperative pain was assessed using visual analog scales and a record was kept of analgesic requirements. Ninety three percent of the patients were satisfied with the pain control and recorded low pain scores and sixty percent of these patients had good pain relief at an average of eighteen hours, without the need for any additional analgesics.

Complications and early results after operative fixation of 68 pilon fractures of the distal tibia.

Background and aims In this cohort study, we present comprehensive injury specific and surgical outcome data from one of the largest reported series of pilon fractures of the distal tibia treated in a UK tertiary referral centre. Methods and results A series of 68 closed pilon fractures were retrospectively reviewed from case notes, plain radiographs and computed tomography imaging. Patient demographics, injury and fracture patterns, methods and timing of fixation and clinical and radiological outcomes were assessed over a mean follow-up period of 7.7 months (1.5–30). Overall, deep infection occurred in 1.6% with superficial infection and wound breakdown occurring in 6.3% of cases. Rates of nonunion and malunion were 7.8%. Radiological posttraumatic arthritis was present in 26.6%, which was symptomatic and requiring orthopaedic management in 9.4%. Further surgery for all causes occurred in 26.6% of cases. Conclusion Fixation of these complex fractures in subspecialist units can achieve overall low rates of wound complications, with definitive fixation of selected fractures within 48 h of initial presentation achieving comparable results to those fixed in a delayed fashion. However, this injury continues to have a significant overall complication rate with a high chance of developing early posttraumatic arthritis and of requiring further surgery.

Quantitative assessment of the subchondral vascularity of the talar dome: A cadaveric study

BACKGROUND The arterial supply to the talus has been extensively studied previously but never to specifically examine the subchondral region of the talar dome, a frequent site of localised pathology. This study aims to analyse and quantify the subchondral vascularity of the talar dome. METHODS We performed cadaveric arterial injection studies. After processing, the vascularity to the subchondral region of the talar dome was visualised and mapped using three-dimensional computer technology, then quantified and reported using a nine-section anatomical grid. RESULTS The areas of relative poor perfusion across the talar dome are the posterior/medial, posterior/lateral and middle/medial sections of a nine-section grid. The rest of the subchondral region shows more richly vascularised bone. CONCLUSIONS The vascularity of the subchondral surface of the talar dome is not uniformly distributed. This may be relevant to the aetiology and management of osteochondral lesions and shows some correlation with their more frequent locations.

An Anatomical Study Comparing Two Surgical Approaches for Isolated Talonavicular Arthrodesis

Background: Two operative approaches are commonly used for isolated talonavicular arthrodesis: the medial and the dorsal approach. It is recognized that access to the lateral aspect of the talonavicular joint can be limited when using the medial approach, and it is our experience that using the dorsal approach addresses this issue. We performed an anatomical study using cadaver specimens, to compare the amount of articular surface that can be accessed by each operative approach. Methods: Medial and dorsal approaches to the talonavicular joint were performed on each of 11 cadaveric specimens (10 fresh frozen, 1 embalmed). Distraction of the joint was performed as used intraoperatively and the accessible area of articular surfaces was marked for each of the 2 approaches using a previously reported technique. Disarticulation was performed and the marked surface area was quantified using an immersion digital microscribe, allowing a 3-dimensional virtual model of the articular surfaces to be assessed. Results: The median percentage of total accessible talonavicular articular surface area for the medial and dorsal approaches was 71% and 92%, respectively (Wilcoxon signed-rank test, P < .001). Conclusion: This study provides quantifiable measurements of the articular surface accessible by the medial and dorsal approaches to the talonavicular joint. Clinical Relevance: These data support for the use of the dorsal approach for talonavicular arthrodesis, particularly in cases where access to the lateral half of the joint is necessary.

The anterior approach for the fixation of displaced talar neck fractures—A cadaveric study

BACKGROUND Talar neck fractures are rare and are associated with high complication rates. Adequate surgical exposure is essential in the operative management of these challenging injuries. The anterior approach is an alternative to the more commonly described and utilized anterolateral and anteromedial approaches. OBJECTIVE The main objective was to compare the surface area of talus visible and quality of exposure via the anterior approach, with the anteromedial and anterolateral approaches. MATERIALS AND METHODS An anterior approach was performed on five fresh frozen cadaveric specimens. The surface area of talus visible was measured using an Immersion Digital Microscribe and analyzed with the Rhinoceros 3D graphics package. Standard anterolateral and anteromedial approaches were performed in the same specimens and areas visible measured using the same method. RESULTS The talar surface area visible using the anterior approach is significantly greater than that visible using the anterolateral approach or anteromedial, without and with medial malleolar osteotomy, as well as combination approaches. CONCLUSION The anterior approach offers excellent visualization in the fixation of displaced talar neck fractures. Greater talar surface area is visible using this approach compared to traditional approaches.

Supracondylar Femoral Nail in the management of non-union of humeral shaft fractures

We reviewed seven patients with established non-union of a shaft of humerus fracture, treated by locked intramedullary nailing using the Intramedullary Supracondylar Nail (IMSC Nail; Smith & Nephew Richards, Memphis TN). The mean age of the patients was 65 years (range 48-78 years). Three of the fractures involved the proximal third of the diaphysis while the remaining four involved the middle third. Six of the original fractures were closed and one was an open fracture. The time interval between the original injury and final surgery averaged 9.3 months. All the nailings were done by the ante-grade approach with static locking. Six of the patients had closed nailing and one had open nailing with bone grafting. The mean follow-up was 8 months and osseous union was achieved in all seven cases at a mean of 5.6 months. We conclude that the Supracondylar Femoral Nail is a useful alternative implant in the management of non-union of fractures of the humeral shaft with wide medullary canals.