Christopher J. Vertullo

Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete.

Background Midfoot sprains in athletes represent a spectrum of injuries to the Lisfranc ligament complex, from partial sprains with no displacement to complete tears with frank diastasis. Treatment of these injuries varies from the treatment of high-velocity injuries seen in nonathletes. Purpose We wanted to report the outcome of treatment in athletes with Lisfranc injuries classified according to our system. Study Design Retrospective cohort study. Methods Weightbearing radiographs and bone scintigrams were used to diagnose midfoot sprains in 15 athletes who were treated surgically or nonoperatively according to the following classification: nonoperative management for stage I injuries (undisplaced) and anatomic reduction with fixation for stage II (diastasis with no arch height loss) and stage III (diastasis with arch height loss) injuries. Results We achieved an excellent outcome in 93% of 15 athletes with midfoot sprains at an average follow-up of 27 months (range, 9 to 72). Conclusions Weightbearing radiographs and bone scintigrams are sensitive, reproducible, and relatively inexpensive methods of investigation of these injuries. Restoration and maintenance of the anatomic alignment of the Lisfranc joint is the key to appropriate treatment of injury to the midfoot.

Total ankle arthroplasty.

&NA; First‐generation total ankle arthroplaty designs had unacceptably high complication and failure rates compared with ankle arthrodesis. More recent prostheses have had encouraging intermediate results because of refined surgical techniques and improved designs. Mobile‐bearing designs theoretically offer less wear and loosening through full conformity and minimal constraint. The less complex fixed‐bearing designs avoid bearing dislocation and the potential for added wear from a second articulation. Four second‐generation designs have demonstrated reasonable functional outcomes: the Scandinavian Total Ankle Replacement, the Agility Ankle, the Buechel‐Pappas Total Ankle Replacement, and the TNK ankle. Intermediate results are promising but should be interpreted with care.

Torsional Strains in the Proximal Fifth Metatarsal: Implications for Jones and Stress Fracture Management

Background: Reports of nonunion of proximal fifth metatarsal fractures treated by internal fixation indicate that current fixation methods do not always adequately address the stresses to which the bone is subjected during ambulation. In particular, the insertion sites of the peroneus brevis and peroneus tertius tendons on the fifth metatarsal suggest that their actions can impose torsional stresses on the areas of the bone in which Jones fractures and stress fractures occur. Intramedullary screw fixation, however, offers little resistance to rotation of the proximal and distal fragments relative to one another. Methods: To determine the potential for the existence of torsional stresses in the fifth metatarsal during post-operative ambulation, a simplified cadaver model of single-limb stance was used in which cadaver feet were subjected to concurrent axial and tendon forces while monitoring the outputs of stacked rosette strain gauges placed at the typical sites of Jones and stress fractures. Principal strain and shear strain magnitudes and directions were measured. Results: The shear strain magnitudes and strain axis directions indicated the presence of torsional stresses in the underlying bone potentially capable of causing internal rotation of the proximal fragment relative to the distal end of the bone. Conclusions: This finding has implications for the treatment of both Jones fractures and stress fractures of the proximal fifth metatarsal. An internal fixation device that has the capability to resist torsion as well as tension and bending would appear optimal to treat these fractures.

Mobile Bearings in Primary Knee Arthroplasty

&NA; Mobile‐bearing knee arthroplasty (MBKA) has potential advantages compared with conventional fixed‐bearing total knee arthroplasty (TKA). By allowing unconstrained axial rotation, MBKA can offer greater articular conformity without an increased probability of loosening due to increased axial torque. Increased articular conformity minimizes polyethylene contact stresses, thereby reducing linear wear and subsurface fatigue failure. Axial rotation of the platform also enables self‐correction of tibial component malrotation. Despite these advantages, the long‐term clinical results obtained with current MBKA devices are similar to those obtained with well‐designed fixed‐bearing TKA prostheses, with no data suggesting their superiority. The disadvantages of MBKA include bearing dislocation and breakage, soft‐tissue impingement, a steep technique learning curve, and concerns about volumetric wear. Hypothetically, longer‐term followup of MBKA results may reveal a significant difference from fixed‐bearing TKA results as the fatigue failure threshold of incongruent polyethylene is exceeded.

Acquired Flatfoot Deformity Following Posterior Tibial Tendon Transfer for Peroneal Nerve Injury : A Case Report

Anterior transfer of the posterior tibial tendon is a well-recognized surgical procedure that is used to restore active ankle dorsiflexion that has been lost secondary to peroneal nerve deficiency1,2. The many causes of peroneal nerve deficiency include knee or hip trauma, surgical misadventure, tumor, and mononeuropathy3,4. The tibialis posterior muscle is the primary dynamic stabilizer of the medial longitudinal arch of the foot and is the primary initiator of hindfoot inversion5,6. Normal toe-off during gait requires hindfoot inversion to lock the transverse tarsal joints and hence transform the supple foot into a rigid lever arm for push-off. The normal antagonist muscle to the tibialis posterior is the peroneus brevis, which everts the hindfoot. Theoretically, patients who have undergone posterior tibial tendon transfer should be at greater risk for the development of a flatfoot deformity secondary to the absence of function of the posterior tibialis muscle because of the increased stresses that are placed on the static soft-tissue supports on the medial side of the hindfoot. The plantar calcaneonavicular (spring) ligament complex appears to be the most important of these static medial soft-tissue supports. Interestingly, we are aware of no reported cases of acquired adult flatfoot deformity following transfer of the posterior tibial tendon for the correction of a peroneal nerve palsy. Some authors have speculated that this lack of flatfoot development is due to the absence of active eversion of the hindfoot because the peroneus brevis is paralytic3, but others have disagreed7. We report the case of a patient in whom a symptomatic flatfoot deformity developed after an anterior transfer of the posterior tibial tendon and the flexor hallucis longus tendon was performed to restore active dorsiflexion following a peroneal nerve injury. A forty-six-year-old …

Participation in sports after arthrodesis of the foot or ankle

Currently no data or guidelines exist for the surgeon on how to advise patients about returning to sports participation after arthrodesis within the foot or ankle. Sequelae of inappropriate activity after arthrodesis includes periarticular arthrosis, arthrodesis failure and stress fracture. Some arthrodeses will preclude certain sports because it limits the patients ability to perform movement vital to the game, for example, ankle arthrodesis preventing basketball players from jumping. Questionnaires were sent to members of the American Orthopædic Foot and Ankle Society (AOFAS) and to trainers of professional basketball and American football teams. This paper reports on the responses of orthopædic foot and ankle surgeons about return to sports participation, after arthrodeses within the foot and ankle, and suggests guidelines for sports participation after an arthrodesis of the lower extremity. A selective sports participation policy is advised. Patients with an ankle or triple fusion should avoid high-impact sports, while those with more distal arthrodeses should be monitored for arthrosis and stress fracture.

The transverse dorsal approach to the Lisfranc joint.

While multiple longitudinal skin incisions can be utilized to visualize the joints of the midfoot, we feel that exposure can be difficult. Dorsal transverse and T incisions were undertaken to expose the tarsometatarsal joints (TMTJs) in 12 patients. Five of the 12 had some form of immunosuppression, including diabetes, methotrexate therapy and antirejection transplant therapy. One patient who had a lengthening of the midfoot with a structural autograft suffered a small area of skin necrosis that healed by secondary intention. The remainder of patients wounds healed without complication. Three to six dorsal access intervals are created between the neurovascular and musculotendinous structures that overlie the TMTJs. The transverse incision can be extended into a medially based T incision to apply a medial plate as required. Transverse incisions are not recommended for patients who require lengthening of the midfoot.

Twelve-year Outcomes of an Oxinium Total Knee Replacement Compared with the Same Cobalt-chromium Design: An Analysis of 17,577 Prostheses from the Australian Orthopaedic Association National Joint Replacement Registry.

Background: Oxidized zirconium (Oxinium) was introduced as an alternative bearing surface to cobalt-chromium (CoCr) in an attempt to reduce polyethylene wear and decrease aseptic mechanical failure of total knee replacements. While noncomparative reports have been described as promising, we were aware of no short or long-term clinical studies showing the superiority of Oxinium on polyethylene as a bearing surface. Using data from a comprehensive national joint replacement registry, we compared the long-term outcomes after cruciate-retaining total knee arthroplasty (TKA) with an Oxinium femoral component and those with the same prosthetic design but with a CoCr femoral component. Methods: The cohorts consisted of 17,577 cemented Genesis-II cruciate-retaining total knee replacements using non-cross-linked polyethylene, which included 11,608 with CoCr femoral components and 5,969 with Oxinium femoral components. The cumulative percent revision and hazard ratio (HR) for revision risk were estimated for the cemented Genesis-II Oxinium and CoCr cruciate-retaining TKAs performed in Australia from September 1, 1999, to December 31, 2013. In addition, the revision diagnoses and the effects of age and patellar resurfacing were examined. Results: No difference in the HR for revision risk was found between the Oxinium and CoCr cohorts for any age category for all causes of revision (HR = 0.92 [95% confidence interval (CI), 0.78 to 1.08]; p = 0.329), loosening or lysis, or aseptic causes, except for loosening or lysis in the group of patients who were ≥75 years old (p = 0.033). In these patients, TKA with Oxinium femoral components had a higher rate of revision. Younger patients preferentially received Oxinium femoral components. The revision risk was not affected by patellar resurfacing or nonresurfacing. At 12 years, the cumulative percent revision was 4.8% (95% CI, 4.2% to 5.4%) for the CoCr Genesis-II prosthesis compared with 7.7% (95% CI, 6.2% to 9.5%) for the Oxinium Genesis-II prosthesis. Conclusions: In this cohort study involving the same prosthetic design, Oxinium femoral components did not reduce revision rates for all causes, loosening or lysis, or when infection as a cause of revision was removed compared with the same CoCr femoral component across all age groups including patients who were <55 years old. The cumulative percent revision was greater for the Oxinium components than for the CoCr components. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Effect on Long-term Survivorship of Surgeon Preference for Posterior-stabilized or Minimally Stabilized Total Knee Replacement: An Analysis of 63,416 Prostheses from the Australian Orthopaedic Association National Joint Replacement Registry

Background: Controversy still exists as to the optimum management of the posterior cruciate ligament (PCL) in total knee arthroplasty. Surgeons can choose to kinematically substitute the PCL with a posterior-stabilized total knee replacement or alternatively to utilize a cruciate-retaining, also known as minimally stabilized, total knee replacement. Proponents of posterior-stabilized total knee replacement propose that the reported lower survivorship in registries when directly compared with minimally stabilized total knee replacement is due to confounders such as selection bias because of the preferential usage of posterior-stabilized total knee replacement in more complex or severe cases. In this study, we aimed to eliminate these possible confounders by performing an instrumental variable analysis based on surgeon preference to choose either posterior-stabilized or minimally stabilized total knee replacement, rather than the actual prosthesis received. Methods: Cumulative percent revision, hazard ratio (HR), and revision diagnosis data were obtained from the Australian Orthopaedic Association National Joint Replacement Registry from September 1, 1999, to December 31, 2014, for 2 cohorts of patients, those treated by high-volume surgeons who preferred minimally stabilized replacements and those treated by high-volume surgeons who preferred posterior-stabilized replacements. All patients had a diagnosis of osteoarthritis and underwent fixed-bearing total knee replacement with patellar resurfacing. Results: At 13 years, the cumulative percent revision was 5.0% (95% confidence interval [CI], 4.0% to 6.2%) for the surgeons who preferred the minimally stabilized replacements compared with 6.0% (95% CI, 4.2% to 8.5%) for the surgeons who preferred the posterior-stabilized replacements. The revision risk for the surgeons who preferred posterior-stabilized replacements was significantly higher for all causes (HR = 1.45 [95% CI, 1.30 to 1.63]; p < 0.001), for loosening or lysis (HR = 1.93 [95% CI, 1.58 to 2.37]; p < 0.001), and for infection (HR = 1.51 [95% CI, 1.25 to 1.82]; p < 0.001). This finding was irrespective of patient age and was evident with cemented fixation and with both cross-linked polyethylene and non-cross-linked polyethylene. However, the higher revision risk was only evident in male patients. Conclusions: There was a 45% higher risk of revision for the patients of surgeons who preferred a posterior-stabilized total knee replacement compared with the patients of surgeons who preferred a minimally stabilized total knee replacement. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Effect on Long Term Survivorship of Surgeon Preference for Posterior Stabilized or Minimally Stabilized Total Knee Replacement: An Analysis of 63416 Cases from the AOANJRR

Introduction & Aims: Controversy still exists as to the optimum management of the PCL in TKR, with registry data suggesting Posterior Stabilised TKR have a higher Cumulative Percent Revision (CPR) compared to Minimally Stabilised TKR. Proponents of PS TKR suggest this difference is due to selection bias as result of preferential use of PS TKR in complex or more severe cases. To remove this selection bias, we aimed to compare CPR based on surgeon TKR stability preference to treat with PS or MS TKR rather than actual prosthesis type received. Method: Observational series. An analysis of AOANJRR data from 1999 – 2014 was utilized to identify two cohorts of high volume surgeons who preferred to use routinely either MS or PS TKR. Only fixed tibial inserts and patellar resurfacing TKR were included. A MS preferring surgeon used MS TKR at least 90% of the time and a PS preferring surgeon used PS TKR at least 90% of the time. Consequently, each patient cohort included both PS and MS TKR in differing proportions. Results: Procedures undertaken by PS preferring surgeons had a significantly higher risk of revision (CPR (Hazard Ratio = 1.45 (95% CI 1.30, 1.63), p< 0.001). There was a higher rate of revision for loosening and infection in the PS group. Of the 39 941 TKR with cemented fixation of both femur and tibia, the PS preferring surgeons had a higher CPR than the MS preferring cohort (HR = 1.55 (1.33, 1.80), p< 0.001). Regardless of whether the polyethylene was crosslinked or non-crosslinked, the MS preferring surgeons had a lower CPR compared to the PS preferring surgeons. Conclusions: In this analysis, procedures undertaken by surgeons who mainly preferred to use PS TKR had a higher rate of revision than those that mainly used MS TKR. This finding was irrespective of patient age and was also evident when fixation and the type of polyethylene used was taken into account.