Ibukunoluwa Araoye

Gastrocnemius recession for recalcitrant plantar fasciitis in overweight and obese patients

BACKGROUND Plantar fasciitis is a common foot pathology that is typically treated non-operatively. However, a minority of patients fail non-operative management, develop chronic symptoms, and request a surgical option. Gastrocnemius recession has recently been shown to be effective for the treatment of chronic plantar fasciitis. The purpose of this paper is to present evidence that gastrocnemius recession is safe and effective in the subset of chronic plantar fasciitis patients who are overweight and obese. METHODS We retrospectively reviewed 18 cases (17 patients) of chronic plantar fasciitis in overweight or obese patients who underwent gastrocnemius recession (mean age=46years, mean body mass index=34.7kg/m2, mean follow-up=20months). Data was gathered regarding pre-operative and post-operative pain (visual analog scale, 0-10), Foot Function Index score, and complications. RESULTS Mean Foot Function Index score improved from 66.4 (range, 32.3-97.7) preoperatively to 26.5 (range, 0-89.4) postoperatively (p<0.01). Mean pain score improved from 8.3 (range, 5-10) preoperatively to 2.4 (range, 0-7) at final follow-up (p<0.01). CONCLUSIONS Gastrocnemius recession improved foot function and pain symptoms in overweight and obese patients with chronic plantar fasciitis.

ROLE OF BONE GRAFTS AND BONE GRAFT SUBSTITUTES IN ISOLATED SUBTALAR JOINT ARTHRODESIS

ABSTRACT Objectives: The purpose of this study was to compare union rates for isolated subtalar arthrodesis with and without the use of bone grafts or bone graft substitutes. Methods: We retrospectively reviewed 135 subtalar fusions with a mean follow-up of 18 ± 14 months. The standard approach was used for all surgeries. Graft materials included b-tricalcium phosphate, demineralized bone matrix, iliac crest autograft and allograft, and allograft cancellous chips. Successful subtalar fusion was determined clinically and radiographically. Results: There was an 88% (37/42) union rate without graft use and an 83% (78/93) union rate with bone graft use. Odds ratio of union for graft versus no graft was 0.703 (95% CI, 0.237-2.08). The average time to union in the graft group was 3 ± 0.73 months and 3 ± 0.86 in the non-graft group, with no statistically significant difference detected (p = 0.56). Conclusion: Graft use did not improve union rates for subtalar arthrodesis. Level of Evidence IV, Case Series.

A systematic review and meta-analysis of complications in conversion arthroplasty methods for failed intertrochanteric fracture fixation

Background Conversion arthroplasty for failed primary fixation of intertrochanteric fractures can be achieved using various methods, including cemented total hip arthroplasty, uncemented total hip arthroplasty, hybrid total hip arthroplasty, and hemiarthroplasty. Complication rates vary between each conversion method. The purpose of this paper is to examine the effect of conversion method on total conversion complication rates. Methods We performed a meta-analysis of five studies with sufficient data for analysis. We created a null hypothesis stating that the expected distribution of complications across conversion methods would reflect the distribution of conversion method used for failed primary fixation. Using a z test, we compared proportions of the expected distribution of complications to the observed distribution of complications. Results A total of 138 cases of conversion arthroplasty with 49 complications were available for analysis. The mean age was 73 (range, 32-96) years. 19 males and 48 females were included, with one study not including patient gender. The mean time from primary fixation failure to conversion was 11 months, and the mean duration of conversion surgery was 132 min. Expected and observed complication rate distributions were as follows: cemented total hip arthroplasty, 6.5% versus 4.1% (p = 0.79); uncemented total hip arthroplasty, 77.5% versus 81.6% (p = 0.69); hybrid total hip arthroplasty, 2.9% versus 2.0% (p = 1); and hemiarthroplasty, 13% versus 12.2% (p = 1). Conclusions Our findings suggest that the method of conversion arthroplasty following failed primary intertrochanteric femur fracture fixation does not influence complication rate.

The success rate of First Metatarsophalangeal Joint Lateral Soft Tissue Release through a Medial Transarticular Approach: A Cadaveric Study

BACKGROUND The objective of this study was to evaluate the success rate of first metatarsophalangeal joint (MTPJ) lateral soft tissue release through a medial transarticular approach. METHODS Ten cadaveric specimens were used (6 females/4 males, mean age, 73.4years). Lateral release was performed through a 4cm medial approach using a number 15 blade. Surgical aim was to release four specific structures: lateral capsule, lateral collateral ligament (LCL), adductor hallucis tendon (AHT) and lateral metatarsosesamoid suspensory ligament (LMSL). Once completed, a dissection of the first intermetatarsal space was performed. Success rate was graded in accordance to the number of structures successfully released: 0% (no structures), 25% (1/4), 50% (2/4), 75% (3/4) and 100% (4/4). Inadvertent injuries to other soft tissue structures were recorded. RESULTS The success rate for lateral soft tissue release was 100% in 7 cadaveric specimens, and respectively 75%, 50% and 25% in the other 3 specimens. The LCL was successfully released in all specimens. The lateral joint capsule, AHT and LMSL were released in 80% of the specimens. Chondral damage to the first metatarsal head, unintended release of the conjoined tendon and lateral head of the flexor hallucis brevis (FHB) occurred respectively in 40%, 50% and 20% of the specimens. CONCLUSIONS Our cadaveric study demonstrated high success rate in the release of specific lateral soft tissue structures of the first MTPJ through a medial transarticular approach. Inadvertent release of the lateral head of the FHB, conjoined tendon and iatrogenic chondral damage of the first metatarsal head are complications to be considered. LEVEL OF EVIDENCE Cadaveric study - Level V.

Revisiting the Prevalence of Associated Copathologies in Chronic Lateral Ankle Instability: Are There Any Predictors of Outcome?

Background: Multiple ankle pathologies have been found to coexist with chronic lateral ankle ligament instability, but their prevalence varies widely in the literature. The purpose of this study is to reexamine the prevalence of these associated pathologies and to determine their impact on reoperation rate. Methods: We retrospectively reviewed 382 cases of lateral ankle ligament repair/reconstruction between June 2006 and November 2016. Patient charts and radiograph reports were examined for the presence of any associated foot and ankle pathologies as well as clinical course. The effect of copathologies on reoperation rate was examined using binary logistic regression and the χ2 test. Results: We included a total of 99 cases. Copathologies included peroneal pathology (75/99, 75.8%), ankle impingement (40/99, 40.4%), and osteochondral lesion of the talus (17/99, 17.2%); 36.4% (36/99) had a low-lying muscle belly of peroneus brevis. The total reoperation rate was 12/92 (13.1%). It was lower in cases with peroneal pathology (8.7% vs 27.5%, P = .032). Conclusion: Peroneal pathology, ankle impingement, and osteochondral lesions were the most common associated copathologies in surgical patients with chronic lateral ankle ligament instability. The presence of peroneal pathology may lead to fewer reoperations, possibly as a result of a more comprehensive first-time surgical approach. Level of Evidence: Level III: Retrospective cohort

Percutaneous Posterior to Anterior Screw Fixation of the Talar Neck: Soft Tissue Structures at Risk

Category: Trauma Introduction/Purpose: Fractures of the talar neck and body can be fixed with percutaneously placed screws directed from anterior to posterior or posterior to anterior. The latter has been found to be biomechanically and anatomically superior. Percutaneous pin and screw placement poses anatomic risks for posterolateral and posteromedial neurovascular and tendinous structures. The objective of this study was to enumerate the number of trials for proper placement of two parallel screws and to determine the injury rate to neurovascular and tendinous structures. Methods: Eleven fresh frozen cadaver limbs were used. 2.0 mm guide wires from the Stryker (Selzach, Switzerland) 5.0-mm headless cannulated set were percutaneously placed (under fluoroscopic guidance) into the distal posterolateral aspect of the ankle. All surgical procedures were performed by a fellowship-trained foot and ankle surgeon. Malpositioned pins were left intact to allow later assessment of soft tissue injury. The number of guide wires needed to achieve an acceptable positioning of the implant was noted. Acceptable positioning was defined as in line with the talar neck axis in both AP and lateral fluoroscopic views. After a layered dissection from the skin to the tibia, we evaluated neurovascular and tendinous injuries, and measured the shortest distance between the closest guide pin and the soft tissue structures, using a precision digital caliper. Results: The mean number of guide wires needed to achieve acceptable positioning for 2 parallel screws was 2.91 ± 0.70 (range, 2 - 5). The mean distances between the closest guide pin and the soft tissue structures of interest were: Achilles tendon, 0.53 ± 0.94 mm; flexor hallucis longus tendon, 6.62 ± 3.24 mm; peroneal tendons, 7.51 ± 2.92 mm; and posteromedial neurovascular bundle, 11.73 ± 3.48 mm. The sural bundle was injured in all the specimens, with 8/11 (72.7%) in direct contact with the guide pin and 3/11 (17.3%) having been transected. The peroneal tendons were transected in 1/11 (9%) of the specimens. The Achilles tendon was in contact with the guide pin in 6/11 (54.5%) specimens and transected in 2/11 (18.2%) specimens. Conclusion: The placement of posterior to anterior percutaneous screws for talar neck fixation is technically demanding and multiple guide pins are needed. Our cadaveric study showed that important tendinous and neurovascular structures are in close proximity with the guide pins and that the sural bundle was injured in 100% of the cases. We advise performing a formal small posterolateral approach for proper visualization and retraction of structures at risk. Regardless, adequate patient education about the high risk of injury from this procedure is crucial.

Percutaneous Tendon Achilles Lengthening: What Are We Really Doing?

Category: Hindfoot Introduction/Purpose: Percutaneous Achilles tendon lengthening (TAL) is a common procedure used to address equinus contracture of the foot. A triple hemisection technique has become popular due to its ease and efficiency. Several studies evaluate the surgical outcomes of this procedure, but currently, descriptive anatomical studies are lacking. The objective of the study was to evaluate the accuracy of performing Achilles tendon percutaneous hemisections, the amount of tendon excursion in the tensile gaps of the cuts after forced dorsiflexion and the improvement in the range of motion for dorsiflexion of the ankle joint. Methods: Ten fresh-frozen above-knee cadaveric specimens were used. A percutaneous triple hemisection of theAchilles tendon (proximal, intermediate, and distal) was performed. Maximum ankle dorsiflexion was evaluated pre- and postprocedure with a digital goniometer. After proper dissection, the relative width of the cuts was noted. Followingforced ankle dorsiflexion, displacement in the tensile gaps was measured in all 3 cuts with a precision digital caliper. Results: The overall relative width of the percutaneous cut was 51.3% ± 16.3% of the Achilles tendon diameter, 44.3%± 13.6% for the proximal cut, 50.3% ± 15.6% for the intermediate cut, and 59.3% ± 18.4% for the distal cut. Tendonexcursion averaged 13.0 ± 3.8 mm for the proximal cuts, 12.5 ± 4.7 mm for the intermediate cuts, and 8.2 ± 3.7 mm forthe distal cuts. One cadaver had a complete rupture of the Achilles tendon and was excluded from the excursion dataanalysis. The mean range of motion for ankle dorsiflexion was 8.1 ± 3.9 degrees preprocedure and 27.6 ± 5.3 degreespostprocedure. The dorsiflexion angle significantly increased (P < .0001) at an average of 19.5 ± 5.0 degrees following TAL. Conclusion: Our cadaveric study demonstrated that the percutaneous triple hemisection of the Achilles was an accuratetechnique that provided successful lengthening of the tendon and increased ankle dorsiflexion. Complete ruptures arepossible complications. Our cadaveric study showed that in a clinical situation, triple hemisections of the Achilles tendon can be performed reliably, with significant improvement of the ankle dorsiflexion, mainly through increased tendon excursion at the proximal and intermediate cuts, and with low risk of complete ruptures.

Intraoperative Syndesmotic Instability Test: A Novel Alternative Technique

Category: Ankle, Trauma Introduction/Purpose: Precise diagnosis of distal tibiofibular syndesmotic injury is challenging and a gold standard diagnostic test has still not been established. Tibiofibular clear space identified on radiographic imaging is considered the most reliable indicator of the injury. The Cotton test is the most widely used intraoperative technique to evaluate the syndesmotic integrity although it has its limitations. We advocate for a novel intra operative test using a 3.5 mm cortical tap. Methods: Tibiofibular clear space was assessed in nine cadaveric specimens using three sequential fluoroscopic images. The first image was taken prior to the application of the tap test representing the intact and non-stressed state. Then, a 2.5 mm hole was drilled distally on the lateral fibula, and a 3.5 mm cortical tap was then threaded in the hole. The tap test involved gradually advancing the blunt tip against the lateral tibia, providing a tibiofibular separation force (intact, stressed). This same stress was then applied after all syndesmotic ligaments were released (injured, stressed). Measurements were compared by one-way ANOVA and paired Student’s t-test. Intra and inter-observer agreements were evaluated by intraclass correlation coefficient (ICC). P-values <.05 were considered significant. Results: We found excellent intra-observer (0.97) and inter-observer (0.98) agreement following the imaging assessment. Significant differences were found in the paired comparison between the groups (p<.05). When using an absolute value for TFCS >6 mm as diagnostic for syndesmotic instability, the tap test demonstrated a 96.3% sensitivity and specificity, a 96.3% PPV and NPV and a 96.3% accuracy in diagnosing syndesmotic instability. Conclusion: Our cadaveric study showed that this novel syndesmotic instability test using a 3.5 mm blunt cortical tap is a simple, accurate and reliable technique able to demonstrate significant differences in the tibiofibular clear space when injury was present. It could represent a more controlled and stable low-cost alternative to the most used Cotton test.

Ankle Fusion Percutaneous Home Run Screw Fixation: technical aspects and soft tissue structures at risk

Category: Ankle Arthritis Introduction/Purpose: During internal fixation of ankle fusions, besides the standard crossed screw fixation pattern, the use of a percutaneously placed augmenting screw, directed from the posterolateral tibial metaphysis proximally across the ankle into the talar neck (“ankle fusion home run screw”), is a widely used technique. The placement of this screw is technically demanding and multiple attempts under fluoroscopy guidance are frequently needed to achieve a perfect positioning of the implant. Injuries to local neurovascular and tendinous structures might happen. The objective of this cadaver study was to identify the number of attempts necessary for a perfect positioning of the ankle fusion home run screw and the neurovascular and tendinous structures at risk. Methods: Eleven fresh frozen cadaver limbs were used. Guide wires (3.2 mm) from the Stryker (Selzach, Switzerland) 7.0-mm headless cannulated set were percutaneously placed into the distal posterolateral aspect of the leg, under fluoroscopic guidance, with the ankle held in neutral position. Mal positioned pins were not removed and served as guidance for the following pins. The number of guide wires needed to achieve an acceptable positioning of the implant was noted. After a layered dissection from the skin to the tibia, we evaluated neurovascular and tendinous injuries, and measured the shortest distance between the closest guide pin and the soft tissue structures, using a precision digital caliper. Results: The mean number of guide wires needed to achieve and acceptable positioning of the implant was 2.09 (SD 0.83, range 1- 4). The mean distances between the closest guide pin and the soft tissue structures of interest were: Achilles tendon 6.90 mm (SD 3.74 mm); peroneal tendons 9.65 mm (SD 3.99 mm); sural neurovascular bundle 0.97 mm (SD 1.93 mm); posteromedial neurovascular bundle 14.26 mm (SD 4.56 mm). Sural bundle was in contact with the guide pin in 5/11 specimens (45.5%) and transected in 3/11 specimens (27.3%). Conclusion: The placement of percutaneous ankle fusion home run screws is technically demanding and multiple guide pins are needed. Our cadaveric study showed that important tendinous and neurovascular structures are in close proximity with the guide pins and that the sural bundle is injured in approximately 73% of the cases. Caution should be taken during percutaneous placing of screws and an appropriate approach and surgical dissection to bone is advised.

Is retained bone debris in cannulated orthopedic instruments sterile after autoclaving

Aims: Cannulated surgical instruments may retain biologic debris after routine cleaning and sterilization. Residual debris after cleaning is assumed to be sterile; however, there is no experimental basis for this assumption. The purpose of this study was to determine the sterility of retained biodebris found within cannulated surgical instruments after autoclave sterilization. Materials and Methods: Fifteen cannulated drill bits were used to drill pig scapulae to create a plug of bone that was exposed to a mixture of Bacillus cereus, Pseudomonas aeruginosa, and methicillin‐resistant Staphylococcus aureus for 60, 120, or 180 minutes prior to sterilization. The drill bits were autoclave sterilized using standard settings. The “sterilized” bone cores were then incubated in solution and streak‐plated on blood agar. Results: All 3 positive controls were positive for the experimental bacteria. Two negative controls were positive for contaminant bacteria. A B. cereus strain was recovered from 1 of the experimental group drill bits in the 180‐minute group. Pulsed‐field gel electrophoresis confirmed that the recovered B. cereus strain was identical to the experimental inoculate. Conclusion: Retained biodebris in cannulated drills may not be sterile after standard autoclave sterilization. In addition, delay of surgical instrument reprocessing may increase the risk of resistant contamination.