J. Kent Ellington

Maintenance of hardware after early postoperative infection following fracture internal fixation.

BACKGROUND The development of a deep wound infection in the presence of hardware after open reduction and internal fixation presents a clinical dilemma, and there is scant literature to aid in decision-making. The purpose of the present study was to determine the prevalence of osseous union with maintenance of hardware after the development of postoperative infection within six weeks after internal fixation of a fracture. METHODS The present study included 121 patients from three level-I trauma centers, retrospectively identified from billing and trauma registries, in whom 123 postoperative wound infections with positive intraoperative cultures had developed within six weeks after internal fixation of acute fractures. The incidence of fracture union without hardware removal was calculated, and the parameters that predicted success or failure were evaluated. RESULTS Eighty-six patients (eighty-seven fractures; 71%) had fracture union with operative débridement, retention of hardware, and culture-specific antibiotic treatment and suppression. Predictors of treatment failure were open fracture (p = 0.03) and the presence of an intramedullary nail (p = 0.01). Several variables were not significant but trended toward an association with failure, including smoking, infection with Pseudomonas species, and involvement of the femur, tibia, ankle, or foot. CONCLUSIONS Deep infection after internal fixation of a fracture can be treated successfully with operative débridement, antibiotic suppression, and retention of hardware until fracture union occurs. These results may be improved by patient selection based on certain risk factors and the specific bacteria and implants involved.

Review of 107 Hallux MTP Joint Arthrodesis Using Dome-Shaped Reamers and a Stainless-Steel Dorsal Plate

Background: The purpose of this study was to retrospectively review the results of patients treated with hallux MTP joint arthrodesis using dome-shaped reamers for joint preparation and a precontoured dorsal stainless steel plate for internal fixation. Materials and Methods: A series of 145 patients (155 feet) were identified. Postoperative evaluation included weightbearing radiographs, physical examination, and chart review. Outcomes were assessed with a pain visual analog scale, AOFAS hallux score, as well as a detailed questionnaire and a subjective satisfaction survey. Results: 98 patients (107 feet) met the criteria for the study. The mean followup was 61 weeks. Revision cases accounted for 18.7% (20/107). Rheumatoid arthritis (RA) was present in 32.7% (35/107). The average postoperative AOFAS hallux score was 79.7 and pain VAS was 19. The average pre and postoperative hallux valgus angle was 26.5 and 12.3 degrees, respectively (p < 0.05). Eighty-nine of 107 patients (83.1%) reported good to excellent results at final followup. Discomfort related to prominence of the plate occurred in 14.9% (16/107). The nonunion rate was 12.1% (13/107). The nonunion rate for patients with/without RA was 22.9% (8/35) and 6.9% (5/72), respectively (p < 0.05). Patients with a nonunion noted more hardware related pain than those with a union (p < 0.05). Conclusion: First MTP joint arthrodesis using this technique achieves a high union rate. RA patients have a lower union and higher complication rate. Level of Evidence: IV, Retrospective Case Series

Management of failures of total ankle replacement with the agility total ankle arthroplasty.

BACKGROUND Few studies have focused on treatment following failed total ankle replacement. The purpose of this study was to report the outcomes of patients undergoing revision total ankle replacement and to propose a talar component subsidence grading system that may be helpful in making decisions regarding how to revise failed total ankle replacements in the future. METHODS A retrospective review was performed of fifty-three patients who underwent revision total ankle replacement and had been followed for a minimum of two years. Patients were assessed radiographically and with outcome scores. The rates of conversion to amputation or fusion were also assessed. RESULTS The mean follow-up period was 49.1 months after the revision arthroplasty. The average time from primary total ankle replacement to revision was fifty-one months. Forty-one of the fifty-three patients (77%) were available for follow-up. The revision arthroplasty had been converted to an arthrodesis in five of the forty-one patients, and two additional patients had undergone amputation. The most common indication for revision total ankle replacement was talar subsidence (63%; twenty-six of forty-one). Twenty-two patients (54%) had a subtalar arthrodesis performed at the time of the revision arthroplasty, with nineteen of those having a custom-designed long-stem talar component placed simultaneously. The mean radiographic measurements of component position did not change significantly postoperatively. The mean postoperative scores for the thirty-four patients with a retained total ankle replacement were: 4.4 of 10 possible points on a visual analog pain scale (VAS), 65 of 100 possible points on the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot scale, 93.5 of 100 possible points on the Short-Form 12 (SF-12), 137.9 of 204 possible points on the Revised Foot Function Index (FFI-R), and 64 of 180 possible points on the Ankle Osteoarthritis Scale (AOS). The mean arc of motion radiographically was 18° preoperatively and 23° postoperatively, with all improvement occurring in plantar flexion. A lesser amount of preoperative talar subsidence was a significant predictor of a good outcome based on the AOFAS hindfoot score (p < 0.03) and the AOS (p < 0.01) score. CONCLUSIONS Revision arthroplasty may be considered as an alternative to arthrodesis when treating patients with a failed Agility total ankle implant.

Locked versus Nonlocked Plate Fixation for Hallux MTP Arthrodesis

Background: Dorsal plate fixation is used commonly for arthrodesis of the hallux first metatarsophalangeal (MTP) joint. Custom dorsal plates incorporating locking technology have been developed recently for applications in the foot to provide relative ease of application and theoretically superior mechanical properties. The purpose of this study is to compare the radiographic and clinical outcomes of patients undergoing hallux MTP joint arthrodesis using a locked plate, or a nonlocked plate. Materials and Methods: We compared consecutive patients who underwent hallux MTP arthrodesis for a variety of diagnoses with either a precontoured locked titanium dorsal plate (Group 1) or a precontoured, nonlocked stainless steel plate (Group 2). All patients were evaluated with radiographs, visual analog pain scale, American Orthopaedic Foot and Ankle Society (AOFAS) hallux score, and a detailed patient satisfaction survey. Results: There were 73 feet in Group 1 and 107 feet in Group 2. There was a trend toward a higher nonunion rate in Group 1 compared to Group 2. When considering only patients without rheumatoid arthritis (RA), the union rate was significantly higher in Group 2 compared to Group 1. Hardware failure and the overall complication rate was equivalent between the two Groups. Conclusion: As locked plate technology continues to gain popularity for procedures in the foot, it is important that clinical outcomes are reported. Locked titanium plates were associated with higher nonunion rates. Improved plate design, patient selection, and an understanding of plate biomechanics in this unique loading environment may optimize future outcomes for hallux MTP arthrodesis. Level of Evidence: III, Retrospective Comparative Study

Clinical Outcomes and Complications of Percutaneous Achilles Repair System Versus Open Technique for Acute Achilles Tendon Ruptures

Background: Limited incision techniques for acute Achilles tendon ruptures have been developed in recent years to improve recovery and reduce postoperative complications compared with traditional open repair. The purpose of this retrospective cohort study was to analyze the clinical outcomes and postoperative complications between acute Achilles tendon ruptures treated using a percutaneous Achilles repair system (PARS [Arthrex, Inc, Naples, FL]) versus open repair and evaluate the overall outcomes for operatively treated Achilles ruptures. Methods: Between 2005 and 2014, 270 consecutive cases of operatively treated acute Achilles tendon ruptures were reviewed (101 PARS, 169 open). Patients with Achilles tendinopathy, insertional ruptures, chronic tears, or less than 3-month follow-up were excluded. Operative treatment consisted of a percutaneous technique (PARS) using a 2-cm transverse incision with FiberWire (Arthrex, Inc, Naples, FL) sutures or open repair using a 5- to 8-cm posteromedial incision with FiberWire in a Krackow fashion reinforced with absorbable sutures. Patient demographics were recorded along with medical comorbidities, activity at injury, time from injury to surgery, length of follow-up, return to baseline activities by 5 months, and postoperative complications. Results: The most common activity during injury for both groups was basketball (PARS: 39%, open: 47%). A greater number of patients treated with PARS were able to return to baseline physical activities by 5 months compared with the open group (PARS: 98%, open: 82%; P = .0001). There were no significant differences (P > .05) between groups in rates of rerupture (P = 1.0), sural neuritis (P = .16), wound dehiscence (P = .74), superficial (P = .29) and/or deep infection (P = .29), or reoperation (P = .13). There were no deep vein thromboses (DVTs) or reruptures in either group. In the PARS group, there were no cases of sural neuritis, 3 cases (3%) of superficial wound dehiscence, and 2 reoperations (2%) for superficial foreign-body reaction to FiberWire. In the open group, there were 5 cases (3%) of sural neuritis, 7 cases (4%) of superficial wound dehiscence, 3 cases (2%) of superficial infection, and 3 reoperations (2%) for deep infection. Conclusion: The present study reports the largest single-center series of acute Achilles tendon ruptures in the literature with lower complication rates for operatively treated Achilles ruptures compared with previous reports. The overall complication rate for all operatively treated Achilles ruptures was 8.5% with no reruptures, and most patients (88%) were able to return to baseline activities by 5 months after surgery. There were no significant differences in rates of postoperative complications between PARS and open repair for acute Achilles tendon ruptures. Level of Evidence: Level III, retrospective cohort study.

Radiographic analysis of proximal interphalangeal joint arthrodesis with an intramedullary fusion device for lesser toe deformities.

Background: Lesser toe deformities are frequent and bothersome conditions. Many options exist for the treatment of hammertoes and clawtoes. The purpose of this study was to review our experience with the use of an intramedullary fusion device. Materials and Methods: An IRB approved retrospective review was performed to identify 38 toes in 27 patients treated with the StayFuse™ (Nexa Orthopaedics) device with a mean followup of 31 months. The indications for surgery were primary deformity in 12 toes and recurrent deformities in 26 toes. Results: Union occurred in 23 of 38 (60.5%). The union rate was nine of 12 for primary procedures and 53.8% (14/26) for revisions. Coronal PIP alignment demonstrated no change in 33 of 38 cases (86.8%) and changed in five of 38 (13.2%). Sagittal PIP alignment demonstrated no change in 36 of 38 cases (94.7%), and changed in 2/38 (5.3%). Including nonunion, the overall complication rate was 55.3% (21/38) (15 nonunions; three hardware failures (two (bent) not requiring intervention and one (broke) leading to a rotational deformity requiring revision), one intraoperative fracture (without sequelae), one requiring MP surgery, and one requiring a larger implant. The index surgery for all three of the patients that required a second surgery was for a recurrent deformity. All three patients requiring a second surgery occurred in the nonunion group. Conclusion: The StayFuse™ intramedullary fusion device was efficacious in maintaining PIP alignment in the treatment of lesser toe deformities with a relatively low reoperation rate at mid-term followup. Level of Evidence: IV, Retrospective Case Series

The mangled foot and ankle: results from a 2-year prospective study.

Objective: To determine the outcome of the mangled foot and ankle undergoing limb salvage surgery that required free tissue flaps for wound closure compared with a similar patient foot and ankle injury group that underwent early below knee amputation (BKA). Design: Prospective longitudinal study. Setting: Eight level 1 trauma centers. Patients/Participants: LEAP (Lower Extremity Assessment Project) study. One hundred seventy-four open severely injured hindfoot or ankle injuries (116 had salvage; 58 had a BKA). Intervention: Patients either required immediate amputation or salvage was attempted. Main Outcome Measurements: The Sickness Impact Profile (SIP) was the principal measure of outcome (higher SIP scores equal greater disability). Secondary outcomes included walking speed, number of rehospitalizations for injury-related complications, time to full weight-bearing, the visual analog pain scale, and return to work at 2 years. Results: When compared to patients treated with standard BKA, salvage patients who required free flaps and/or ankle arthrodesis had significantly worse 2-year outcomes. They had overall SIP scores that were 2.5 points higher and psychosocial SIP scores that were 8.4 points higher at 24 months (P = 0.014 and P = 0.013, respectively). Physical SIP scores were 3.7 points higher in the free flap and/or arthrodesis group but only approached statistical significance (P = 0.10). After adjusting for the need for free flap and/or arthrodesis, the salvage pathway had clinically, but not statistically, significantly better overall and psychosocial SIP scores than the standard BKA patients (P = 0.34 and P = 0.20, respectively). Conclusions: Patients with severe foot and ankle injuries who require free tissue transfer or ankle fusion have SIP outcomes that are significantly worse than BKA with typical skin flap design closure. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

The Use of the Lapidus Procedure for Recurrent Hallux Valgus

Background: The objective of this study was to evaluate the Lapidus procedure or its modifications for treatment of recurrent hallux valgus (HV). Our hypothesis was that the Lapidus procedure would achieve good correction of recurrent HV and patients would be satisfied. Materials and Methods: A retrospective review of 32 feet (30 patients) treated with the Lapidus procedure for recurrent HV with at least 1-year followup was performed. Evaluation included radiographs, examination, and chart review. Outcomes were assessed with a pain visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) hallux score, SF-12, Revised Foot Function Index (RFFI), and a survey. Twenty-three of 30 patients (25 feet) met the criteria for inclusion in the study and were available for followup evaluation. The average followup was 31.6 months. Results: Arthrodesis was present in 24 out of 25 feet (96%). The time from initial HV correction to revision surgery was 91 months. The initial surgery performed was a distal osteotomy (15), proximal osteotomy (five), exostectomy (two), diaphyseal osteotomy (two), and proximal/distal osteotomy (one). Preoperative evaluation revealed 96% of patients had clinical hypermobility of the first TMT joint and 52% had radiographic findings of instability. The average postoperative AOFAS hallux score was 82.8, SF-12 score was 94.5, and RFFI was 101. The average preoperative hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA) were 36.2, 13.6,18.6 degrees, respectively, which corrected to an average of 15.2, 7.5, 11.7 degrees postoperatively (p < 0.001). The average shortening of the first ray was 2.9 mm. Average pain VAS was 2.4. Eighty-seven percent reported good to excellent results. Using a multivariable linear regression analysis, postoperative HVA along with change in length of the first ray were significant predictors of quality of life based on SF-12 (p < 0.05). Conclusion: The Lapidus procedure corrected recurrent HV with a low nonunion rate and excellent radiographic correction and patients were satisfied with their outcome. Level of Evidence: IV, Retrospective Case Series

Peroneal Tendon Displacement Accompanying Intra-articular Calcaneal Fractures

BACKGROUND Peroneal tendon displacement (subluxation or dislocation) accompanying an intra-articular calcaneal fracture is often undetected and under-treated. The goals of this study were to determine (1) the prevalence of peroneal tendon displacement accompanying intra-articular calcaneal fractures, (2) the association of tendon displacement with fracture classifications, (3) the association of tendon displacement with heel width, and (4) the rate of missed diagnosis of the tendon displacement on radiographs and computed tomography (CT) scans and the resulting treatment rate. METHODS A retrospective radiographic review of all calcaneal fractures presenting at three institutions from June 30, 2006, to June 30, 2011, was performed. CT imaging of 421 intra-articular calcaneal fractures involving the posterior facet was available for review. The prevalence of peroneal tendon displacement was noted and its associations with fracture classification and heel width were evaluated. RESULTS Peroneal tendon displacement was identified in 118 (28.0%) of the 421 calcaneal fracture cases. The presence of tendon displacement was significantly associated with joint-depression fractures compared with tongue-type fractures (p < 0.001). Only twelve (10.2%) of the 118 cases of peroneal tendon displacement had been identified in the radiology reports. Although sixty-five (55.1%) of the fractures with tendon displacement had been treated with internal fixation, the tendon displacement was treated surgically in only seven (10.8%) of these cases. CONCLUSIONS Analysis of CT images showed a 28% prevalence of peroneal tendon displacement accompanying intra-articular calcaneal fractures. Surgeons and radiologists are encouraged to consider this association.

Surgical Outcome Following Tibialis Anterior Tendon Repair

Background: Tibialis anterior tendon rupture is an uncommon injury that can cause significant functional deficit. Recent series have supported surgical reconstruction in younger, more active patients. We investigated our clinical outcomes of patients having undergone surgical management of tibialis anterior tendon ruptures. Materials and Methods: Fifteen tibialis anterior tendon ruptures in 14 patients were retrospectively reviewed after surgical management. Five had primary repair, while 10 had tendon transfers. Average age at time of surgery was 70.6 years with an average followup of 27.2 months. Patients were evaluated with American Orthopaedic Foot and Ankle Society (AOFAS) and SF-36 clinical outcome scores. Strength measurements utilizing a dynamometer and range of motion (ROM) were documented on the operative and non-operative ankles. Patient satisfaction surveys were performed. Results: Average postoperative AOFAS hindfoot score was 88.8 and SF-36 score was 76.4. There was a statistically significant difference in average dorsiflexion strength of 21.8 lbs/in2 on the operative side and 28.8 lbs/in2 on the non-operative limb, and in dorsi-flexion ROM of patients that received a gastrocnemius recession. There was no statistically significant difference between primary tendon repair versus tendon transfer groups nor plan-tarflexion strength or ROM among any group. Patient surveys revealed that seven patients were completely satisfied, six had minor reservations, and one had major reservations. There were no complications. Conclusion: This study supports the surgical repair or reconstruction of the tibialis anterior tendon ruptures to restore functional strength and ROM. Level of Evidence: IV, Retrospective Case Series