Graham A. Hamilton

Rates of revision surgery using Chevron-Austin osteotomy, Lapidus arthrodesis, and closing base wedge osteotomy for correction of hallux valgus deformity.

To identify complications that necessitated revision surgery after the primary operation, a multicenter retrospective chart review was conducted for 646 patients who received either a modified chevron-Austin osteotomy (270 patients), modified Lapidus arthrodesis (342 patients), or closing base wedge osteotomy (34 patients) to correct hallux valgus deformity. Revision surgery for complications was calculated and compared. All surgery was performed by 1 of 5 staff foot and ankle surgeons at Kaiser Permanente medical centers. Complications included recurrent hallux valgus, iatrogenic hallux varus, painful retained hardware, nonunion, postoperative infection, and capital fragment dislocation. The rates of revision surgery after Lapidus arthrodesis, closing base wedge osteotomy and chevron-Austin osteotomy were similar with no statistical difference between them. The total rate for re-operation was 5.56% among patients who received chevron-Austin osteotomy, 8.82% among those who had a closing base wedge osteotomy, and 8.19% for patients who received modified Lapidus arthrodesis. Among patients who had the chevron-Austin osteotomy procedure, rates of re-operation were 1.85% for recurrent hallux valgus and 1.48% for hallux varus. Among patients who had the modified Lapidus arthrodesis, rates of re-operation were 2.92% for recurrent hallux valgus and 0.29% for hallux varus. Among patients who had the closing base wedge osteotomy, rates of reoperation were 2.94% for recurrent hallux valgus and 2.94% for hallux varus. The collected comparative complication rates should serve to provide adjunctive information for foot and ankle surgeons and patients regarding hallux valgus surgery.

Complications after open reduction and internal fixation of ankle fractures in the elderly

BACKGROUND Open reduction with internal fixation for unstable ankle fractures is relatively predictable with excellent outcomes. However, the management of ankle fractures in the elderly remains less predictable secondary to the various co-morbidities associated with advanced age. METHODS A retrospective chart review of 216 patients over the age of 60 that sustained an ankle fracture, was performed to determine the incidence of complications after ORIF of ankle fractures in an elderly population in the perioperative course. Secondly, the incidence of complications in patients that had locking plate fixation compared to those that had non-locking plate fixation was determined. Lastly, the effect of early weight bearing on the incidence of complications was analyzed. RESULTS There was not a statistically significant difference in the complication rates between the group with co-morbidities (19.01%) and those without (11.96%). The postoperative complication with the highest incidence was wound dehiscence (9.7%), and only diabetes significantly predicted wound dehiscence. The fixation construct and weight-bearing protocol failed to significantly predict any of the indexed complications. CONCLUSIONS Overall, the results suggest that surgical treatment of unstable ankle fractures in the elderly is fairly predictable with an acceptable complication rate. The complication rates are higher with increased age and diabetes, but they failed to reach statistical significance. Conventional plating appears to provide adequate stability without increased risk of hardware failure. In addition patients that were allowed to walk within the first 2 weeks postoperatively did not experience a higher rate of hardware failure.

Associated intra-articular ankle pathologies in patients with chronic lateral ankle instability: arthroscopic findings at the time of lateral ankle reconstruction.

Chronic lateral ankle instability (CLAI) can be a debilitating condition. The literature has shown that it is also associated with a number of intra-articular pathologies of the ankle. Some argue that if unaddressed, these intra-articular pathologies can predispose patients to osteoarthritis. Previous studies of patients who underwent prelateral stabilization ankle arthroscopy have shown a high number of pathologies, including osteochondral lesions of the talus. Purpose: The current study reviewed a consecutive series of patients diagnosed with CLAI who underwent ankle arthroscopy followed by a modified Brostrom-Gould procedure to validate the previous studies. Methods: Intraoperative reports on 28 ankles in 28 consecutive patients were reviewed from 2004 to 2008. Result: All 28 ankles (100%) demonstrated varying degrees of synovitis. Talar cartilage fibrillation was observed in 7 patients (25%), and talar dome cartilage defect was visualized in 4 patients (14%). Talar dome osteochondral defect was seen in 2 patients (7%), loose bodies were found in 3 patients (11%), Bassett’s lesion was seen in 2 patients (7%), and anterolateral impingement was seen in 4 patients (14%). Distal anterior tibial osteophytosis was seen in 4 patients (14%). Conclusion: This study confirms the high number of intra-articular pathologies in association with CLAI. Level of Evidence: Therapeutic, Level IV

Mesenchymal Stem Cell Allograft in Revision Foot and Ankle Surgery: A Clinical and Radiographic Analysis

UNLABELLED A review was conducted of 23 patients who underwent implantation of mesenchymal stem cell allograft for revision foot or ankle surgery. Composed of viable mesenchymal stem cells derived from cadaveric donor tissue, the graft had osteogenic, osteoinductive, and osteoconductive properties, and was capable of direct new bone formation at the site of implantation. In all of the cases, radiographic new bone formation was observed at the area of implantation and a 91.3% union rate was observed, and no evidence of graft rejection or complications associated with implantation were recorded. Wilcoxon rank sum tests were used to determine whether gender, diabetes, chronic renal insufficiency, neuropathy, number of previous surgeries, and smoking were associated with time to healing. Spearmans rank correlation coefficient was calculated in an effort to identify the influence of continuous numeric variables on the time to bone healing. Based on the outcomes observed in this retrospective study, it appears that mesenchymal stem cell allograft is a beneficial biological adjunct to bone healing, and serves as a suitable bone autograft substitute in revision foot and ankle surgery. LEVEL OF CLINICAL EVIDENCE 4.

Association between ankle fractures and obesity.

Obesity is an epidemic in the United States and is associated with an increased risk of musculoskeletal problems. Rotational injuries of the ankle with a Weber C fibula fracture have a greater risk of syndesmosis disruption and instability. The goal of the present study was to explore the association between obesity and ankle fractures. Using a retrospective review, the radiographs of 280 patients with an ankle fracture were reviewed and classified using the Weber classification, which was then associated with the body mass index, gender, age, diabetes, tobacco use, and osteoporosis. Patients with a body mass index of 30 kg/m(2) or greater (odds ratio 1.78), men (odds ratio 1.74), and age 25 years or younger (odds ratio 3.97) had greater odds of having a Weber C ankle fracture (compared with Weber A and B) and Weber C and B (compared with Weber A). Diabetes mellitus, osteoporosis/osteopenia, and current tobacco use were not significantly associated with the severity of the ankle fracture. The results from the present study suggest that obesity presents a greater risk of sustaining a more proximal distal fibula fracture.

First Metatarsophalangeal Joint Arthrodesis and Revision Arthrodesis

Arthrodesis of the first metatarsophalangeal joint is a powerful procedure that can improve the load-bearing capabilities of the forefoot and assist in medial arch stability. It is the mainstay of treatment for patients with severe arthritic deformity of the great toe joint, because it addresses the importance first ray weight-bearing has on the rest of the foot. In select individuals, fusion can also be effective as a primary procedure in the treatment of hallux valgus. Rather than cause detrimental effects to the function of the foot, this article suggests that first metatarsophalangeal arthrodesis can actually improve faulty mechanics secondary to a dysfunctional joint.

The Effect of the Lapidus Arthrodesis on the Medial Longitudinal Arch: A Radiographic Review

We reviewed the medical records and radiographs of 35 patients (3 males, 32 females; mean age 40.8 years) who underwent isolated, modified Lapidus arthrodesis for forefoot pathology in 39 feet. The purpose of the review was to evaluate the structural radiographic changes of the medial longitudinal arch (MLA) following isolated arthrodesis of the first tarsometatarsal joint. Pre- and postoperative standardized measurements of sagittal plane views of the foot were assessed to examine change in the MLA construct. The talo-first metatarsal angle and medial cuneiform height both had statistically significant changes, 2.97 degrees (range, 0-11.5 degrees) and 3.44 mm (range, 0-13 mm) (P < .0001) respectively. Our findings suggest that the Lapidus arthrodesis may influence the medial longitudinal arch.

Complete Talar Extrusion: A Case Report

UNLABELLED Complete dislocation of the talus is an enigma in the realm of foot and ankle surgery. With the advent of airbags and other sophisticated safety features, more people are surviving motor vehicle accidents and presenting to the emergency department with talar fractures. Most surgeons are aware of the associated risks of avascular necrosis and infection, although large sample studies of talar fractures are scarce in the literature. Moreover, reports of total extrusion of the talus are limited to isolated cases. In this article, the case of a patient who experienced an open, complete talus dislocation, treated with immediate primary repair, is presented. LEVEL OF CLINICAL EVIDENCE 4.

External fixation of the foot and ankle. Elective indications and techniques for external fixation in the midfoot.

Although external fixation is widely used for treatment of fractures, limb deformities, and bone lengthening; use of external devices is still evolving. Elective cases for treatment of the midfoot and published research on external fixation specifically for surgical treatment of midfoot pain and deformity are scarce. Indications for elective external fixation in the midfoot are limited because rigid internal fixation in this area is relatively easy and successful. This article discusses podiatric conditions that can be treated advantageously by external fixation when elective surgery is done. The article also describes methods of external fixation appropriate for podiatric surgical reconstruction in patients with these conditions.

Talus Fractures: Surgical Principles

Surgical treatment of talus fractures can challenge even the most skilled foot and ankle surgeon. Complicated fracture patterns combined with joint dislocation of variable degrees require accurate assessment, sound understanding of principles of fracture care, and broad command of internal fixation techniques needed for successful surgical care. Elimination of unnecessary soft tissue dissection, a low threshold for surgical reduction, liberal use of malleolar osteotomy to expose body fracture, and detailed attention to fracture reduction and joint alignment are critical to the success of treatment. Even with the best surgical care complications are common and seem to correlate with injury severity and open injuries.