Christopher F. Hyer

Treatment of Syndesmotic Disruptions with the Arthrex Tightrope™: A Report of 25 Cases

Background: The complexity of syndesmotic injuries, often with both bone and soft tissue injury mandates an expeditious diagnosis and treatment to avoid unfavorable long term outcomes. Various methods of fixation of the syndesmosis have been reported. We present the largest series evaluating the Arthrex Tightrope™ for management of syndesmotic injuries. Materials and Methods: Twenty-five patients with disruption of the distal tibiofibular articulation underwent treatment with an Arthrex Tightrope™. In 21 cases, a single tightrope was placed, and in four cases, two tightropes were utilized. Associated ankle fractures were treated using proper AO technique. Those patients with diabetes and/or neuroarthropathic changes foot or ankle were not included in this study. Postoperative evaluation parameters included radiographic measurements, a modified AOFAS scoring system and SF-12. Results: Average followup was 10.8 months. The mean time to full weight-bearing was 5.5 (range, 2 to 8) weeks. Postoperative radiographic analysis of the mean distance from the tibial plafond to the placement of the tightrope(s), medial clear space, average postoperative tibiofibular overlap and the mean tibiofibular clear space demonstrated no evidence of re-displacement of the syndesmotic complex at an average of 10.8 (range, 6 to 12) months. The modified AOFAS hindfoot scoring scale and SF-12 both demonstrated significant improvements; preoperative values were assessed in the office with the first patient visit as they are incorporated into the patient intake form that each patient fills out at the initial visit. Conclusion: Utilization of the tightrope in diastasis of the syndesmosis should be considered as a good option. The method of placement is quick, can be minimally invasive, and obviates the need for hardware removal. In this series, it maintained excellent reduction of the syndesmosis.

Transosseous Fixation of the Distal Tibiofibular Syndesmosis: Comparison of an Interosseous Suture and Endobutton to Traditional Screw Fixation in 50 Cases

UNLABELLED In this prospective cohort study, we compared screw fixation to interosseous suture with endobutton repair of the syndesmosis. Outcomes of interest included preoperative and postoperative modified American Orthopedic Foot and Ankle Society (AOFAS) hindfoot and ankle scores, and Short Form-12 health status scores, as well as radiographic measurements and the time to full weight bearing. Mean averages and ranges were calculated for numeric variables, and outcomes for each fixation group were compared statistically with Student t test. The cohort consisted of 50 patients; 25 in the screw fixation group and 25 in the interosseous wire with endobuttons group. The mean patient age was 34.68 (15 to 55) years in the interosseous suture endobutton group and 36.68 (17 to 74) years in the screw group, and the mean follow-up was 10.78 (range 6 to 12) months in the interosseous suture endobutton group, and 8.20 (range 4 to 24) months in the screw group. No statistically significant differences (P < or = .05) were noted in regard to age, follow-up duration, time to postoperative weight bearing, or subjective outcome scores between the fixation groups; although statistically significant improvements were noted in the subjective scores for each fixation group between the preoperative and postoperative measurements. The results of this study indicate that the interosseous suture with endobuttons is a reasonable option for repair of ankle syndesmotic injuries, and may be as effective as traditional internal screw fixation. LEVEL OF CLINICAL EVIDENCE 2.

Interpositional Arthroplasty of the First MTP Joint Using a Regenerative Tissue Matrix for the Treatment of Advanced Hallux Rigidus

Background: Treatment options are limited for young and active patients with hallux rigidus of the first metatarsophalangeal (MTP) joint. Soft-tissue interpositional arthroplasty is a promising alternative. Methods: The surgical technique for interpositional arthroplasty utilizing a human acellular dermal regenerative tissue matrix as a spacer is described. A retrospective review of a consecutive series of the first nine patients with Coughlin grade 3 halux rigidus who underwent this procedure is presented. Five patients were female and four were male, with a mean age of 53.3 years, a mean body mass index of 28.6, and a mean duration of symptoms of 3.1 years. Results: The mean length of followup was 12.7 months, with no reported complications or failures. The mean total AOFAS score and pain sub-score were significantly higher at the most recent followup (87.9 and 34.4, respectively) versus preoperatively (63.9 and 17.8, respectively). Conclusions: These excellent early results and lack of complications may be due to the minimal bone resection associated with the procedure. This technique does not require autograft harvesting, is bone-sparing by preserving the plantar plate, and maintains the natural intrinsics of the joint by preserving its associated tendons and the FHB insertion. The sesamoid articulation also is resurfaced. Although further followup is needed, this technique may offer the young and active patient with advanced hallux rigidus an opportunity to maintain an active lifestyle, while retaining the possibility for more surgical options should the condition progress.

Osteochondral Lesions of the Talus: Predictors of Clinical Outcome:

Background: Osteochondral lesions of the talus (OLT) are a common and challenging condition treated by the orthopedic foot and ankle surgeon. Multiple operative treatment modalities have been recommended, and there are several factors that need to be considered when devising a treatment plan. In this study, we retrospectively reviewed a group of patients treated operatively for osteochondral lesions of the talus to determine factors that may have affected outcome. Methods: A retrospective chart review of clinical, radiographic and operative records was performed for all patients treated for OLTs via marrow stimulation technique. All had a minimum followup of 6 months or until return to full activity, preoperative magnetic resonance imaging (MRI) of the OLT to determine size, and failure of nonoperative treatment. Results: A total of 130 patients were included in the study. This included 64 males and 66 females. The average patient age at the time of surgery was 35.1 ± 13.7 (range, 12 to 73) years. The average followup was 37.2 ± 40.2 (range, 7.43 to 247) weeks. The average size of the lesion was 0.84 ± 0.67 cm2. There were 20 lesions larger than 1.5 cm2 and 110 lesions smaller than 1.5 cm2. There were 113 contained lesions and 17 uncontained lesions. OLTs larger than 1.5 cm2 and uncontained lesions were associated with a poor clinical outcome. Conclusions: The treatment of osteochondral lesions of the talus remains a challenge to the foot and ankle surgeon. Arthroscopic debridement and drilling will often provide satisfactory results. However, larger lesions and uncontained lesions are often associated with inferior functional outcomes and may require a more extensive initial procedure. Level of Evidence: IV, Retrospective Case Series

The Peroneal Tubercle: Description, Classification, and Relevance to Peroneus Longus Tendon Pathology

Background: The size and configuration of the peroneal tubercle has been implicated in the pathogenesis of peroneal tendon tears and tenosynovitis. The purpose of this study was to determine the size and prevalence of the peroneal tubercle and devise a classification scheme according to the structure of the tubercle. Methods: One hundred and seventeen calcanei were selected from 59 human skeletons in an osteological collection (one calcaneus was missing). Three were excluded because of the poor condition, leaving 114 calcanei. The peroneal tubercle was measured in length, height, and depth and its structure subjectively described as flat, prominent, concave, or tunnel for each specimen when present. Results: This study revealed a peroneal tubercle prevalence of 90.4% (103) in 114 calcanei. The average length, height, and depth of the tubercle were 13.04 mm (range 3.61 mm to 26.66 mm), 9.44 mm (range 3.67 mm to 23.40 mm), and 3.13 mm (range 1 to 10), respectively. The peroneal tubercle was classified structurally as flat in 44 (42.7%), prominent in 30 (29.1%), concave in 28 (27.2%), and tunnel in one (1.0%). Conclusion: This data may further help to understand the size and assorted configurations of the peroneal tubercle and how they relate to peroneus longus tendon pathology.

Quantitative Assessment of the Yield of Osteoblastic Connective Tissue Progenitors in Bone Marrow Aspirate from the Iliac Crest, Tibia, and Calcaneus

BACKGROUND It is well known that bone marrow aspirate from the iliac crest contains osteoblastic connective tissue progenitor cells. Alternative harvest sites in foot and ankle surgery include the distal aspect of the tibia and the calcaneus. To our knowledge, no previous studies have characterized the quality of bone marrow aspirate obtained from these alternative sites and compared the results with those of aspirate from the iliac crest. The goal of this study was to determine which anatomic location yields the highest number of osteoblastic progenitor cells. METHODS Forty patients were prospectively enrolled in the study, and separate bone marrow aspirate samples were harvested from the ipsilateral anterior iliac crest, distal tibial metaphysis, and calcaneal body. The aspirate was centrifuged to obtain a concentrate of nucleated cells, which were plated and grown in cell culture. Colonies that stained positive for alkaline phosphatase were counted to estimate the number of osteoblastic progenitor cells in the initial sample. The anatomic locations were compared. Clinical parameters (including sex, age, tobacco use, body mass index, and diabetes) were assessed as possible predictors of osteoblastic progenitor cell yield. RESULTS Osteoblastic progenitor cells were found at each anatomic location. Bone marrow aspirate collected from the iliac crest had a higher mean concentration of osteoblastic progenitor cells compared with the distal aspect of the tibia or the calcaneus (p < 0.0001). There was no significant difference in concentration between the tibia and the calcaneus (p = 0.063). Age, sex, tobacco use, and diabetes were not predictive of osteoblastic progenitor cell yield. CONCLUSIONS Osteoblastic progenitor cells are available in the iliac crest, proximal aspect of the tibia, and calcaneus. However, the iliac crest provided the highest yield of osteoblastic progenitor cells. CLINICAL RELEVANCE The study demonstrated that osteogenic progenitor cells are available in bone marrow aspirate harvested from the tibia or calcaneus as well as the iliac crest. All three sites are easily accessed, with a low risk of adverse events. However, larger volumes of aspirate may be needed from the tibia or calcaneus to approach the yield of cells from the iliac crest.

Negative-pressure Wound Therapy Applied to High-risk Surgical Incisions

Negative-pressure wound therapy (NPWT) is commonly used for chronic wounds, open fractures with soft tissue defects, and coverage over split-thickness skin grafts. NPWT uniformly draws wounds closed by helping to remove interstitial fluid, which contains inflammatory and potentially infectious exudate that could impair healing. Recently in our practice, we have used NPWT in cases involving tenuous incisions, such as those used to access target structures during total ankle replacement or open repair of joint depression calcaneal fractures, in an effort to prevent hematoma or wound dehiscence. Although it is generally understood that NPWT can be efficacious and cost-effective for management of a wide range of lower extremity wounds, we also believe it to be beneficial in the management of low-energy trauma and elective hindfoot and ankle reconstructions, and feel that it has led to decreased pain, swelling, and time to healing in our patients. Based on our experience with ankle arthroplasty and the surgical management of hindfoot and ankle trauma, we believe that the use of NWPT in the immediate postoperative period is both safe and efficacious.

Results of Lapidus Arthrodesis and Locked Plating With Early Weight Bearing

In the endeavor toward Lapidus fusion, the authors have studied a new application of locked plating for the first tarsometatarsal joint. The goal was to assess the time to fusion, time to ambulation, rate of delayed union/nonunion, rate of revision, and need for hardware removal following the use of locked-plate technology in the fusion of the first tarsometatarsal joint. The findings denoted an average of 6.95 weeks to radiographic fusion, an average of 2 weeks to ambulation, a 9.52% rate of asymptomatic mal-union, a 0% rate of delayed union or nonunion, and a 0% rate of revision. The rate of need for hardware removal was 4.76%.

Early Weight Bearing of Calcaneal Fractures Fixated With Locked Plates: A Radiographic Review

The use of locked plate technology in the calcaneus has been shown in previous studies to provide greater stability than that of nonlocking plates. The purpose of this study is to examine the radiographic effects of early weight bearing of calcaneal fractures repaired with locked plating. A retrospective review was performed of 17 calcaneal fractures repaired with locked plate fixation over a 2-year period. A chart and radiographic review evaluated the time the patient was kept non—weight bearing and the Bohler’s angle at first postoperative visit and final postoperative visit. Change in Bohler’s angle was used to evaluate for bone subsidence. Standard reduction and fixation techniques were performed to realign all components of the intra-articular calcaneal fracture using a titanium locking calcaneal fracture plate. Patients returned for follow-up examinations postoperatively and underwent radiographic examination. A weight-bearing short fracture walker boot was applied, and the patient began protected weight bearing at approximately 4 to 5 weeks. The charts and radiographs of 17 intra-articular fractures were reviewed. The average Bohler’s angle at first postoperative visit was 30.12° in comparison to the average at final visit of 28.47 °. The average time the patient was kept non—weight bearing after the procedure was 4.8 weeks. The average time of follow-up was 237.7 days. There were no cases of significant bone subsidence or collapse noted. Calcaneal fractures can have significant morbidity associated with the injury and its care. This study examined early weight bearing of calcaneal fractures fixated with locked plating. Under radiographic review, there was no significant loss of calcaneal height, joint reduction, or fixation stability noted. These results are thought to be due to the inherent stability of the locked plate construct.

Treatment of Lisfranc fracture dislocations with an interosseous suture button technique: a review of 3 cases.

UNLABELLED Lisfranc fracture dislocations are complex and difficult to treat. Making the correct diagnosis and achieving an anatomical reduction are important factors in regard to achieving a favorable outcome with this injury. We describe a new technique that we have found to be useful for stabilizing Lisfranc fracture dislocations. This method is relatively fast, minimally invasive, and effective, and it eliminates the need for implant removal. To date, we have achieved predictable results for stabilizing and treating these difficult injuries with the use of a suture endobutton, instead of traditional interfragmental screw fixation. In this report, we describe 3 cases in which this method was used with satisfactory short-term results. LEVEL OF CLINICAL EVIDENCE 4.