Emily A. Cook

Meta-analysis of first metatarsophalangeal joint implant arthroplasty.

UNLABELLED Management of late-stage degenerative joint disease of the first metatarsophalangeal joint (MPJ) is a complex topic that is frequently the source of debate among foot and ankle surgeons. Several surgical interventions have been described to treat this condition. One of the most contested of these treatments is implant arthroplasty of the first MPJ. The primary aim of this meta-analysis was to evaluate the clinical benefit of first MPJ implant arthroplasty in regard to patient satisfaction. Reviewers formally trained in meta-analysis abstraction techniques searched databases and indices using medical subject heading terms and other methods to identify all relevant studies published since 1990. Initially, 3874 citations were identified and evaluated for relevance. Abstract screening produced 112 articles to be read in entirety, of which 47 articles studying 3049 procedures with a mean 61.48 (SD 45.03) month follow-up met all prospective inclusion criteria necessary for analysis. Overall crude patient satisfaction following first MPJ implant arthroplasty was 85.7% (95% confidence interval: 82.5%-88.3%). When adjusting for lower quality studies (retrospective, less than 5 years of follow-up, higher percent of patients lost to follow-up), the overall patient satisfaction increased to 94.5% (89.6%-97.2%) in the highest-quality studies. This adjustment also significantly decreased heterogeneity across studies (crude Q = 184.6, high-quality studies Q = 2.053). Additional a priori sources of heterogeneity were evaluated by subgroup analysis and meta-regression. In regards to patient satisfaction, this comprehensive analysis provides supportive evidence to the clinical benefit of first MPJ implant arthroplasties. LEVEL OF CLINICAL EVIDENCE 1.

A Retrospective Clinical Study of 188 Consecutive Patients to Examine the Effectiveness of a Biologically Active Cryopreserved Human Skin Allograft (TheraSkin ®) on the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers

A biologically active human skin allograft, currently distributed under the brand name TheraSkin®, was examined for safety and efficacy in the treatment of venous leg ulcers (VLUs) and diabetic foot ulcers (DFUs). The objective was to determine if TheraSkin could serve as a safe and effective alternative to bioengineered skin substitutes such as Apligraf® and Dermagraft®. The authors conducted a retrospective study of 214 consecutive patients seen at the Inova Wound Center (Mt Vernon, Virginia), with either a DFU or a VLU. After excluding patients who did not meet the study criteria, the final eligible cohort consisted of 188 subjects, with 134 VLUs and 54 DFUs. Multivariate logistic regression was used to evaluate the relationship between baseline wound size and the proportion of healed wounds after 12 and 20 weeks from initial allograft application. The authors found that by the 12th week, DFUs closed 60.38% of the time and VLUs closed 60.77% of the time. After 20 weeks, the number of closed DFUs increased to 74.1% and the number of VLUs increased to 74.6%. The mean wound size in the DFU group was 6.2 cm2 (±11.8) and 11.8 cm2 (±22.5) in the VLU group. The mean number of TheraSkin allografts required ranged from 1 to 8, with an average of 2.03 (±1.47) at the 12-week point and an average of 3.23 (±2.77) at the 20-week point. Multivariate logistic regression was used to calculate the odds of wound healing by week 12 and week 20 in each group. The authors also analyzed adverse events and found TheraSkin to be noncontributory to any adverse events, verifying the safety of TheraSkin in this study population. In this study, TheraSkin has been shown to be highly effective for the treatment of both VLUs and DFUs with an acceptable safety profile. Level of Evidence: Therapeutic, Level IV

Bone Graft Substitutes and Allografts for Reconstruction of the Foot and Ankle

In reconstructive foot and ankle surgery, the use of bone graft is common. Whether for trauma, acquired or congenital deformities, arthrodeses, joint replacement, bone loss from infection, or bone tumor resection, the foot and ankle surgeon must be knowledgeable about current bone grafting options to make informed decisions. Innovation and technologic advances have produced an impressive and exciting array of options, advancing us closer to mimicking the gold standard: autograft. However, the sheer volume of available products makes it challenging for the foot and ankle surgeon to stay abreast of current bone graft technology. The purpose of this article is to simplify and classify current bone grafting options, discuss advantages and disadvantages, and provide relevant clinical examples.

Validation of the American College of Foot and Ankle Surgeons Scoring Scales.

The American College of Foot and Ankle Surgeons (ACFAS) assembled a task force to develop a scoring scale that could be used by the membership and practitioners-at-large. The original publication that introduced the scale focused primarily on use of the scale and provided only brief background on the development of the health measurement instrument. Concerns regarding the validity and reliability of the scale were raised within the professional community, and ACFAS assembled a task force to address these concerns. The purpose of this article is to address the issues raised by reporting the detailed methods used in the development of the ACFAS Scoring Scales. The authors who constitute this task force reviewed the body of work previously conducted and applied standards that serve to evaluate the scoring scale for: 1) validity, 2) reliability, and 3) sensitivity to change. The results showed that a systematic and comprehensive approach was used in the development of the scoring scales, and the task force concluded that the statistical methods and instrument development process for all 4 modules of the scoring scales were conducted in an appropriate manner. Furthermore, modules 1 and 2 have been rigorously assessed and the elements of these modules have been shown to meet standards for validity, reliability, and sensitivity to change.

Healing in the New Millennium: Bone Stimulators : An Overview of Where We've Been and Where We May be Heading

Electromagnetic fields and their uses in bone healing have been fairly well studied, with most results showing improvement in healing of both bone and cartilage. Most supportive data are found in relation to the spine, femur, and tibia, but there is increasing evidence for its use in the foot and ankle for treatment of nonunions and as an adjunctive device in arthrodeses, particularly in high-risk populations. There are varying data and a significant variety of quality in the current research and publications concerning the use of electrical bone stimulation in the treatment of the foot and ankle. Thus, there is a definite need for further investigation and high-quality study designs to determine the most effective treatment modalities and pathologies best used with bone stimulation. Bone stimulation should be viewed as an adjunctive procedure in which the surgeon optimizes the high-risk patient both medically or surgically whenever possible. But when used appropriately, bone stimulation has the potential to influence outcomes and aid in bone healing when complications arise and in high-risk populations.

Identifying Risk Factors in Subtalar Arthroereisis Explantation: A Propensity-matched Analysis

A case-control study was undertaken to identify differences in patients with flexible flatfoot deformity who required explantation of subtalar arthroereisis compared with those who did not. All patients who required removal of a self-locking wedge-type subtalar arthroereisis were identified between 2002 and 2008. Propensity scores matched 22 explanted subtalar arthroereises to 44 controls (nonexplanted arthroereises), resulting in a total of 66 implants that met all inclusion and exclusion criteria. Multivariate logistic regression found that patients who required explantation had a greater odds of radiographic undercorrection, determined from radiographic anteroposterior talar-first metatarsal angles postoperatively, P = .0012, odds ratio (OR) = 1.175 (95% confidence interval [CI] 1.066 to 1.295), or residual transverse plane-dominant deformities, as determined from radiographic calcaneocuboid abduction angles postoperatively, P = .05, OR = 1.096 (95% CI 1.06 to 1.203). Patients with smaller postoperative anteroposterior talocalcaneal angles had a 16.7% reduction in odds for arthroereisis explantation (P = .0019) (95% CI 6.5% to 25.8%). Age, gender, implant size, shape, duration, implant position, surgeon experience, and concomitant procedures were not statistically different between the 2 groups. This study helps identify key factors that may result in subtalar arthroereisis explantation.

Tenotomy and Tendon Transfer About the Forefoot, Midfoot and Hindfoot

Tendon lengthening and transfer are essential surgical procedures for every foot and ankle surgeon to master, because they are useful in restoring balance and correcting flexible foot deformities. These techniques are even more useful in treating the high-risk patient, because they involve minimal soft-tissue injury and maximum preservation of vascularity. The primary goal of this article is to supplement the foot and ankle surgeons options for treating static and dynamic foot deformities in the high-risk patient by discussing useful tendon lengthening and transfer procedures about the forefoot, midfoot, and hindfoot.

Bioscaffolds and the reconstruction of ligaments and tendons in the foot and ankle.

Biologic scaffolds have become an integral part of surgical soft tissue reconstruction in recent years. The increased use of these materials can be partially attributed to poor long-term outcomes with synthetic products as well as the cost and morbidity associated with allografts and autografts. Bioscaffolds can augment natural healing processes of tendons and ligaments while providing additional structural support. Although these implants lack the mechanical strength of synthetics and other transplants, proper preparation can optimize their load-sharing capacity. This article presents methods that can improve these characteristics of bioscaffolds. Available studies in foot and ankle applications have shown minimal complications in a variety of techniques.

Bioengineered alternative tissues.

Bioengineered alternative tissues (BATs) are heterogeneous processed materials used to aid in wound closure of diabetic foot ulcers. There has been significant progress in the development and clinical use of BATs in the last decade. BATs may be derived from an autograft, allograft, or xenograft source. They may be a single-layer material and consist of only an epidermal or dermal component or they may be bilayer, consisting of both epidermal and dermal components. The holy grail of tissue replacement has yet to be discovered. Nevertheless, if researchers and bioengineers can flip the switch to return cells to their prenatal period, this can be a breakthrough in cellular regeneration.

Anatomic Reconstruction Versus Traditional Rebalancing in Lesser Metatarsophalangeal Joint Reconstruction

ABSTRACT Traditional rebalancing techniques, such as capsulotomies and capsulorrhaphies, are commonly performed during complex hammertoe and lesser metatarsal osteotomy procedures involving metatarsophalangeal joint (MTPJ) contractures; however, floating toes, digital instability, and malalignment are concerns. We critically analyzed the outcomes after anatomic reconstruction of the plantar plate and collateral ligaments compared with those after traditional rebalancing techniques. A case‐control study was conducted of 54 patients who had undergone surgical correction of lesser MTPJ imbalances due to complex hammertoe deformities (power 80%, type I error = 0.05). Cases were defined as consecutive patients treated with anatomic plantar plate and collateral ligament reconstruction. Controls had undergone traditional lesser MTPJ rebalancing and were matched to cases by age, gender, follow‐up duration (minimum 12 months), and concomitant procedures of the same lesser ray. Multivariate logistic regression demonstrated that patients treated with anatomic reconstruction had greater digital stability (negative dorsal drawer and negative paper pull‐out test findings) at final follow‐up examination compared with the controls. American College of Foot and Ankle Surgeons (ACFAS) forefoot module scores were greater in the anatomic group in all domains (p ≤ .05). Controls had greater postoperative radiographic MTPJ angles than the cases, with no differences detected between the 2 groups in visual analog scale scores or proximal interphalangeal joint angles. The importance of restoration of the plantar plate and collateral ligament integrity as a digital stabilizer is generally accepted but has not been well studied. We found that anatomic reconstruction yielded greater digital stability, greater ACFAS Forefoot module scores, and better radiographic MTPJ alignment than controls. Additional studies are warranted to assess the long‐term viability of anatomic lesser MTPJ reconstruction. Level of Clinical Evidence: 3