Daniel B. Ryssman

Surgical Strategies: The Management of Varus Ankle Deformity with Joint Replacement:

Correction of significant deformity in the coronal plane can be challenging when performing a total ankle replacement. Restoration of neutral alignment and congruent articulation are important factors in achieving a successful outcome. Failure to correct coronal plane deformity in the ankle may lead to increased talar tilt, edge loading and accelerated polyethylene wear, component loosening, and early failure.3,5,8,13 In addition, ankle malalignment after replacement may lead to progressive ligamentous instability, deformity, and pain.

Sonographic Visualization of the First Branch of the Lateral Plantar Nerve (Baxter Nerve) Technique and Validation Using Perineural Injections in a Cadaveric Model

The primary purpose of this investigation was to document the ability of high‐resolution sonography to accurately identify the first branch of the lateral plantar nerve (FBLPN) using sonographically guided perineural injections in an unembalmed cadaveric model.

Tendon Transfers for the Adult Flexible Cavovarus Foot

Correction of the adult cavovarus foot deformity, whether rigid or flexible, can be quite challenging. While there are many causes of this deformity, the universal problem is the loss of muscle balanc...

RNA-seq analysis of clinical-grade osteochondral allografts reveals activation of early response genes

Preservation of osteochondral allografts used for transplantation is critical to ensure favorable outcomes for patients after surgical treatment of cartilage defects. To study the biological effects of protocols currently used for cartilage storage, we investigated differences in gene expression between stored allograft cartilage and fresh cartilage from living donors using high throughput molecular screening strategies. We applied next generation RNA sequencing (RNA‐seq) and real‐time reverse transcription quantitative polymerase chain reaction (RT‐qPCR) to assess genome‐wide differences in mRNA expression between stored allograft cartilage and fresh cartilage tissue from living donors. Gene ontology analysis was used to characterize biological pathways associated with differentially expressed genes. Our studies establish reduced levels of mRNAs encoding cartilage related extracellular matrix (ECM) proteins (i.e., COL1A1, COL2A1, COL10A1, ACAN, DCN, HAPLN1, TNC, and COMP) in stored cartilage. These changes occur concomitantly with increased expression of “early response genes” that encode transcription factors mediating stress/cytoprotective responses (i.e., EGR1, EGR2, EGR3, MYC, FOS, FOSB, FOSL1, FOSL2, JUN, JUNB, and JUND). The elevated expression of “early response genes” and reduced levels of ECM‐related mRNAs in stored cartilage allografts suggests that tissue viability may be maintained by a cytoprotective program that reduces cell metabolic activity. These findings have potential implications for future studies focused on quality assessment and clinical optimization of osteochondral allografts used for cartilage transplantation.

Total Ankle Arthroplasty: Management of Varus Deformity at the Ankle:

When performing ankle replacement, correction of coronal plane deformity is challenging and many alternative techniques are available to restore neutral alignment with a congruent articulation, some of which we have previously described.16 The purpose of this paper is to expand upon these alternative procedures, particularly as they relate to varus deformity at the level of the ankle joint. Factors leading to these deformities include chronic lateral ankle instability, post-traumatic arthritis, inflammatory arthritis, or neurologic conditions such as hereditary sensory motor neuropathy, stroke, and polio.8 We have to assume that failure to correct coronal plane deformity will eventually lead to failure of the implant, regardless of the position of the foot. With residual ankle malalignment in varus, increased talar tilt, edge loading, accelerated polyethylene wear, component loosening and mechanical failure will follow regardless of where the location of the varus malalignment comes from, i.e., deformity above the ankle joint, at the joint level, or below the ankle. Deformity at the joint level can be either intra-articular or extra-articular. Intra-articular varus deformity often results from degenerative changes and erosion of the medial tibial plafond. This is associated with a congruent ankle joint. On the other hand, extra-articular varus deformity at the level of the ankle is usually seen with an incongruent ankle joint. This

Radiographic and Functional Outcomes Following Bilateral Ankle Fusions

Background: Ankle arthrodesis is considered to be a well-accepted technique for end-stage ankle arthritis. Our purpose was to evaluate outcomes of patients with bilateral ankle arthrodeses with attention to radiographic and functional outcomes. Methods: Medical records of 31 patients were reviewed from 1977 through 2007. All patients had 1 year of clinical follow-up after their contralateral ankle arthrodesis, with an average follow-up of 11.2 years following the initial arthrodesis. Pertinent patient demographics and information pertaining to the operative procedure, complications, and subsequent adjacent joint fusions was collected. Radiographs were reviewed for time to fusion and adjacent joint arthritis. Functional outcomes were measured using the Foot and Ankle Ability Measure (FAAM) and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle and Hindfoot scale. Results: Ten females and 21 males underwent bilateral ankle fusions at an average age of 57 years at the time of the initial fusion. The contralateral fusion occurred on average 3.1 years following the initial fusion. Radiographic fusion occurred 12 weeks following the initial fusion and 14 weeks following the contralateral fusion. There was a significant increase (P = .0001) in the average AOFAS score postoperatively in both ankles. The average FAAM score at last follow-up was 70. Adjacent joint arthritis developed in the majority of patients; however, most of the patients were free from adjacent fusions and reported their function as “normal” or “nearly normal” at last follow-up. Conclusion: Bilateral ankle arthrodesis was an acceptable treatment option for patients with bilateral, end-stage ankle arthritis. Level of Evidence: Level IV, retrospective case series.

Reconstruction of the Spring Ligament With a Posterior Tibial Tendon Autograft: Technique Tip:

The spring ligament is the main static supporter of the medial longitudinal arch. It functions as a sling to support the talar head and prevent it from falling into plantarflexion and adduction. In patients with adult-acquired flatfoot deformity, the posterior tibial tendon and spring ligament are often deficient, resulting in peritalar subluxation and valgus heel malalignment. Several reconstructive options have been described for the spring ligament, both in clinical studies as well as in cadaveric models. These involve either direct imbrication of the ligament with reinforcement or routing of tendons through bone tunnels. In almost all of these tendon procedures, at least 2 or more bone tunnels are required. These tunnels are often in nonanatomic locations, and the operative techniques involve complex tendon routing schemes. Each additional bone tunnel provides a potential site for complications and failure of tendon-bone healing. Nonanatomic tendon paths may create forces that incorrectly align the peritalar subluxation deformity. We present a novel procedure to reconstruct the failed spring ligament in flatfoot patients who have not completely ruptured their posterior tibial tendon (PTT). The PTT is released proximally with its distal attachment left intact. The proximal stump is then passed through a single bone tunnel in the sustentaculum and tensioned to re-create the spring ligament (Figure 1).

Case report: The nest technique for management of a periprosthetic patellar fracture with severe bone loss

Periprosthetic patellar fracture with marked loss of bone stock presents a significant problem in total knee arthroplasty. Treatment outcomes are often unsatisfying and may lead to disruption of the extensor mechanism of the knee. We present a patient with a Type IIIb periprosthetic patellar fracture treated by a novel approach. Three Steinmann pins were used to reduce the patella and form scaffold for bone graft and a patellar button was cemented into the construct. At 7 years followup, the patient has maintained excellent range of motion, reports no knee pain, has healed the patella fracture, and has restored patellar bone stock.

Outcomes following treatment of the infected Achilles tendon

Methods: We retrospectively reviewed the medical records of 20 patients who had undergone surgical treatment for an infected Achilles tendon between 2000 and 2016. The mean follow-up time was 21 months (range 2-68 months). All patients underwent extensive debridement of the tendon with removal of all infected tissue and foreign material. Soft tissue wound coverage was utilized for large wounds that were not amenable to primary or secondary closure. All patients received culture specific intravenous antibiotics for three to six weeks. Postoperatively, the extremity was immobilized in a splint followed by a cast until the wound was healed. The cast was then replaced with a walking boot and the patients were provided a physical therapy program. Functional outcomes were measured using the Foot and Ankle Ability Measure (FAAM) Activity of Daily Living (ADL) scale.