Jeffrey D. Seybold

Posterior pilon fractures: a retrospective case series and proposed classification system.

Background: Posterior malleolus fractures occur in 7% to 44% of ankle fractures and are associated with worse clinical outcomes. Fractures that involve the posteromedial plafond extending to the medial malleolus have been described previously in small case series. Failure to identify this fracture pattern has led to poor clinical outcomes and persistent talar subluxation. The purpose of this study was to report our outcomes following fixation of this posterior pilon fracture and to describe a novel classification system to help guide operative planning and fixation. Methods: Eleven patients were identified following fixation of a posterior pilon fracture over a 4-year span; 7 returned at minimum 1-year follow-up to complete a physical examination, radiographs, and RAND-36 (health-related quality of life score developed at RAND [Research and Development Corporation] as part of the Medical Outcomes Study) and American Orthopaedic Foot & Ankle Society (AOFAS) ankle/hindfoot questionnaires. Patient records were reviewed to evaluate for secondary complications or operative procedures. Results: Our mean postoperative AOFAS ankle/hindfoot score was 82. Anatomical reduction of the plafond was noted radiographically in 7 of 11 patients, with the remainder demonstrating less than 2 mm of articular incongruity. Five of 7 patients demonstrated ankle and hindfoot range of motion within 5 degrees of the uninvolved extremity. Four complications required operative intervention; 2 patients reported continued pain secondary to development of CRPS. Conclusion: The posterior pilon fracture is a challenging fracture pattern to treat, and it has unique characteristics that require careful attention to operative technique. Our results following fixation of this fracture pattern are comparable with results in the literature. In addition, a novel classification scheme is described to guide recognition and treatment of this fracture pattern. Level of Evidence: Level IV, retrospective case series.

Alcohol Sclerosing Therapy is Not an Effective Treatment for Interdigital Neuroma

Background: Alcohol sclerosing therapy has been reported as a safe and effective means of treating interdigital neuromas, both with or without ultrasound. The use of ultrasound introduces beside the ultrasound device, increased cost, and the need for skilled technicians and may reduce usability, especially in the outpatient clinic. We report a series of patients with interdigital neuroma treated using ethanol sclerosing therapy in a clinic setting without the use of ultrasound. Materials and Methods: We retrospectively reviewed charts of 32 consecutive patients who were enrolled to receive a series of sclerosing ethanol injections from June 2009 to April 2010 for the treatment of a painful interdigital neuroma. Plain radiographs and MRI scans were obtained if clinically indicated to assistance with the diagnosis. Duration and quality of symptoms were recorded and current pain levels were evaluated on a visual analog pain scale. Previous treatments, including orthotic use, corticosteroid injection, or prior neuroma resection were reported. A solution of 1 ml consisting of 20% ethanol and 0.25% bupivacain solution was injected without the use of ultrasound into the affected webspace. The mixture was provided by the local pharmacy. Technical success was confirmed by the temporary resolution of pain following local anesthetic infiltration. If still symptomatic, an injection was repeated every 2 weeks, with most patients receiving a series of four injections. Pain was evaluated on a visual analog pain scale at each visit. Treatment success was defined as resolution of pain as expressed by the patient. Results: Of the 32 patients successful relief of symptoms was only achieved in seven patients, while 25 showed no significant reduction of symptoms and considered or underwent a surgical excision. Conclusion: Alcohol sclerosing therapy administered in the clinic setting without alcohol is not an effective treatment in the nonoperative management of painful interdigital neuromas and has been abandoned in our clinic. Level of Evidence: IV, Retrospective Case Series

An analysis of the orthopaedic in-training examination sports section: The importance of reviewing the current orthopaedic subspecialty literature

The Orthopaedic In-Training Examination (OITE), produced by the American Academy of Orthopaedic Surgeons, was first administered in 1963. It was the first surgical subspecialty examination of its kind to be administered to resident trainees. The inaugural OITE consisted of 150 questions derived from the American Board of Orthopaedic Surgery (ABOS) examination1. The number of questions on the OITE and the number of examinees taking the test have increased substantially during subsequent test administrations. The most recent examination (2008) consisted of 275 questions that were administered to 4137 examinees. The current test is divided into twelve domains: sports medicine, foot and ankle, hand, hip and reconstruction, medically related issues, orthopaedic diseases, basic science and tumors, pediatric orthopaedics, rehabilitation, shoulder and elbow, spine, and musculoskeletal trauma. After the OITE examination, the score reports are returned to individual examinees, along with a list of preferred responses for each question and associated literature or textbook references. As a result, the OITE serves as an important educational tool identifying areas of weakness and future study for individual examinees. Recently, Frassica et al.2 and Marker et al.3 published analyses of the OITE pathology and hand sections. The information derived from these studies enables trainees to study more comprehensively, facilitating the development of a core orthopaedic knowledge base. Additionally, faculty may use this information to direct journal club topics and didactic lectures and to improve their educational curriculum. To our knowledge, no analysis of the sports medicine questions on the OITE has been published. The purpose of this study was to systematically examine the OITE sports medicine questions, along with the associated answers and recommended reading lists, during a five-year period. This analysis produced a list of commonly tested topics and provides an educational resource that residents and attending surgeons may use to …

Outcome of Lateral Transfer of the FHL or FDL for Concomitant Peroneal Tendon Tears

Background: Concomitant tears of the peroneus longus and brevis tendons are rare injuries, with literature limited to case reports and small patient series. Only 1 recent study directly compared the results of single-stage lateral deep flexor transfer, and no previous series objectively evaluated power and balance following transfer. The purpose of this study was to evaluate clinical outcomes, patient satisfaction, and objective power and balance data following single-stage flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendon transfers for treatment of concomitant peroneus longus and brevis tears. Methods: Over an 8-year period (2005-2012), 9 patients underwent lateral transfer of the FHL or FDL tendon for treatment of concomitant peroneus longus and brevis tears. All but 1 patient underwent additional procedures to address hindfoot malalignment or other contributing deformity at the time of surgery. Mean age was 56.9 years, and average body mass index was 27.9. Lateral transfer of the FHL was performed in 5 patients, and FDL transfer performed in 4 with mean follow-up 35.7 months (range: 11-94). Eight of 9 patients completed SF-12 and Foot Function Index (FFI) scores, and 7 returned for range of motion (ROM) and manual strength testing of the involved and normal extremities. These 7 patients also completed force plate balance tests, in addition to peak force and power testing on a PrimusRS machine with a certified physical therapist. Results: All patients were satisfied with the results of the procedure. Mean SF-12 physical and mental scores were 32 and 55, respectively; mean FFI total score was 56.7. No postoperative infections were noted. Two patients continued to utilize orthotics or braces, and 2 patients reported occasional pain with weightbearing activity. Three patients noted mild paresthesias in the distribution of the sural nerve and 2 demonstrated tibial neuritis. All patients demonstrated 4/5 eversion strength in the involved extremity. Average loss of inversion and eversion ROM were 24.7% and 27.2% of normal, respectively. Mean postoperative eversion peak force and power were decreased greater than 55% relative to the normal extremity. Patients demonstrated nearly 50% increases in both center-of-pressure tracing length and velocity during balance testing. There were no statistically significant differences between the FHL and FDL transfer groups with regards to clinical examination or objective power and balance tests. Conclusion: The FHL and FDL tendons were both successful options for lateral transfer in cases of concomitant peroneus longus and brevis tears. Objective measurements of strength and balance demonstrated significant deficits in the operative extremity, even years following the procedure. These differences, however, did not appear to alter or inhibit patient activity levels or high satisfaction rates with the procedure. Although anatomic studies have demonstrated benefits of FHL transfer over the FDL tendon, further studies with increased patient numbers are needed to determine if these differences are clinically significant. Level of Evidence: Level IV, retrospective case series.

Analysis of the orthopedic in-training examination (OITE) musculoskeletal trauma questions.

OBJECTIVES Residency program directors are responsible for providing assessment and feedback about resident performance and for developing a comprehensive resident curriculum in orthopedic surgery. One measure of resident knowledge is the Orthopedic In-Training Examination (OITE). Scores of the OITE examination have been found to correlate with the American Board of Orthopedic Surgery Part 1 Certifying Examination. The purpose of this study was to identify commonly tested orthopedic trauma topics, the taxonomic distribution of questions, and literature references in the OITE to aid curriculum development and individual test preparation. METHODS The musculoskeletal trauma-related questions on the OITE during a 5-year period (2004-2008) were reviewed, and the number of questions, topics, taxonomic classification, and educational references associated with each question were analyzed. RESULTS Nearly 30% of questions each year consist of musculoskeletal trauma-related topics. Femur, tibia, and hip fractures were the most commonly tested topics. The majority (65.6%) of musculoskeletal trauma questions tested recall of specific facts. Examiners referenced primary literature sources (74.9%) more than textbooks (25.1%). The Journal of Bone and Joint Surgery (American) and the Journal of Orthopaedic Trauma were cited most, accounting for 44.3% of all journal references. Forty-seven percent of the primary references were published within 5 years of the test administration. CONCLUSIONS One method for assessing orthopedic knowledge is the OITE examination. Longitudinal analysis of trauma-related questions shows a consistent pattern of both topics and primary literature citation. This information may be used to help guide structured review for future OITE examinations and develop an orthopedic trauma curriculum for a residency program.

Management of Posterior Impingement in the Ankle in Athletes and Dancers

Foot & Ankle International is the official journal of the American Orthopaedic Foot & Ankle Society whose focus is upon “Reconstruction, Sports Medicine, Trauma, and Technology” of foot and ankle problems. The Editorial Board has decided to increase our focus on sports medicine papers. Thus, starting with the following article, the journal will be publishing a series of reviews on important foot and ankle sports-related conditions. We will also be soliciting more foot and ankle scientific papers. As the foot and ankle journal with the highest Journal Impact Factor, we aim to publish the top papers in all of the various areas outlined above.

Tophaceous pseudogout of the ankle: case report.

Level of Evidence: V, Expert Opinion

Surgical Management of Posttraumatic Midfoot Deformity and Arthritis

Posttraumatic joint disruption and deformity remains one of the most common etiologies for midfoot degenerative joint disease. Patients presenting with midfoot arthritis commonly complain of increased pain with weight-bearing activity, and tenderness over the dorsum of the foot with constrictive shoe wear secondary to dorsal osteophyte formation. Nonoperative measures assist with symptom control, focusing on limiting both pain and deformity. Operative intervention is generally considered after an adequate trial of nonoperative measures. Arthrodesis procedures remain the “gold standard” for operative treatment of midfoot arthritis. Interpositional tendon arthroplasty of the fourth and fifth tarsometatarsal joints has been supported as a motion-sparing alternative to arthrodesis for patients with lateral column disease. The indications, complications, postoperative management, and techniques for posttraumatic midfoot arthritis procedures are discussed in further detail below. Level of Evidence: Diagnostic Level 5. See Instructions for Authors for a complete description of levels of evidence.

Primary Triple Arthrodesis for Management of Rigid Flatfoot Deformity

Introduction Primary triple arthrodesis is a powerful and reliable procedure for stabilizing and correcting painful rigid flatfoot deformities with a low rate of complications. Indications & Contraindications Step 1 Preoperative Planning Pay careful attention to the history, physical examination, and weight-bearing radiographic studies as they are critical for selecting patients who will benefit from a triple arthrodesis. Step 2 Room Setup and Patient Positioning Position the patient supine on the operating table with the toes pointing straight up to the ceiling. Step 3 Incisions and Exposure For a standard triple arthrodesis, use 2 incisions: a lateral sinus tarsi incision, which allows exposure of the subtalar joint, CC joint, and lateral aspect of the TN joint, and a medial incision, which provides exposure of the TN joint. Step 4 Joint Preparation Ensure that joint preparation is thorough as this is critical for the success of any hindfoot arthrodesis. Step 5 Reduction of Deformity Reduce the TN joint first, followed by the subtalar joint, restoring a plantigrade foot and approximately 5° of hindfoot valgus alignment. Step 6 Joint Fixation Perform rigid fixation of the subtalar joint first, followed by fixation of the TN and CC joints. Step 7 Accessory Procedures Accessory procedures are often required in addition to the triple arthrodesis to ensure that appropriate hindfoot alignment and a plantigrade foot are achieved. Step 8 Wound Closure Perform a staged wound closure, taking care to maximize soft-tissue coverage over the involved hindfoot joints. Step 9 Postoperative Care Ensure that the patient follows strict non-weight-bearing precautions in the immediate postoperative period to limit micromotion at the arthrodesis sites and allow for timely fusion. Results In one of the largest published series of patients managed with triple arthrodesis (111 patients), Pell et al. reported a union rate of 98% at a minimum follow-up of 2 years, with 91% of patients indicating that they would be willing to repeat the procedure under similar circumstances4. Pitfalls & Challenges

Foot & ankle international.

Thank you very much for your interest and comments on our article published in the February 2013 issue of Foot & Ankle International. We agree that articular impaction is a component of this injury and clearly will negatively affect the function of patients. However, when one is considering this injury pattern, the presence of articular comminution should not play a role in determining the need for fixation. The surgical approach does require addressing the impacted fragments. Primarily, we have noted that articular impaction will preclude indirect reduction of the posterolateral fracture as has been historically described. As described in the article, the fragments are either reduced from a cranial to caudal direction or excised if reduction cannot be achieved. The use of the fracture lines to determine the need for fixation is based on the consideration that joint stability is the critical factor of this injury. Amorosa et al describe fixation for fracture with a minimum of 20% involvement of the posterior plafond. We believe that the size of the fragment does not play a critical role in determining the need for fixation. The importance of anatomic reduction and fixation of the posterolateral and posteromedial fragment to prevent late subluxation with associated degenerative changes is what we have chosen to emphasize. All cases in our series did not have articular impaction as that was not a factor in determining the need for operative intervention. In the experience described by Weber, restoration of joint congruity with an osteotomy resulted in improved clinical outcomes, despite inability to correct articular impaction. Therefore, we believe that it is appropriate to consider posterior plafond fracture without articular comminution a “posterior pilon” to emphasize the importance of the injury and the need to restore joint congruity to minimize arthrosis. This is similar to a traditional pilon fracture that involves the articular surface without articular comminution; the presence of comminution does not alter the need for operative reduction and stabilization to restore joint congruity and minimize arthrosis. Reduction of the involved articular impaction is difficult, as you have described. In this fracture pattern and in our experience, there has not been the need for bone grafting proximal to the articular fragment. The computed tomography scans that we presented in the article are representative of the size of the involved articular fragments in our series and that described by Weber without the presence of a significant bone void following reduction. The use of K-wires to stabilize the fragments is described in the article by Wang et al, as you have referenced. However, in their description, the fragments were reduced indirectly via the posterolateral approach and assessed by fluoroscopy. The secondary posteromedial approach they described was for visualization of reduction of the large posteromedial fragment and fixation and not for assessment of the reduction of the articular fragments. This critique regarding our described technique for reduction applies to their technique as well. This is expected as one cannot directly visualize the reduction given the anatomical structure of the distal tibia. Stabilization of the fragments with a K-wire is an excellent suggestion, although given the small fragment sizes noted in our series, such stabilization may be difficult to achieve. Your described technique would be excellent for larger fragments that are amenable to fixation. The classification system was based on our experience of low-energy injuries that did not involve a known axial loading mechanism, which was not explicitly stated, as you have pointed out. No patient had a fracture pattern in which the posterior colliculus was persistently attached to the anterior colliculus of the medial malleolus. As we continue to collect data on this injury, we may encounter that pattern. In the article by Wang et al, a type II injury is described in 5 patients in whom the posterior malleolus and the anterior aspect were one piece: 3 of these cases were electric bike accidents that would not be considered in our series because this situation imparts a higher energy mechanism. Given the limited number of patients, we may not have encountered this pattern in our specific cohort. This variation exists, as you have stated, and the classification can be modified for our type I patient to state that a single posteromedial fragment is present. This will include the specific variation you describe and would not alter the surgical approach that we describe for type I. Thank you for comments regarding the syndesmotic disruption. We agree that Amorosa et al have described this additional injury and this was not noted in our review of the literature. Our diagnosis of instability, however, is determined by preoperative imaging as opposed to intraoperative determination of instability via fluoroscopy. We do routinely perform intraoperative stress testing; however, are we concerned that with direct stabilization of the posterior lateral malleolus, instability may not be detected via stress testing. Therefore, preoperative 3-D imaging is important to determine disruption of the anterior tibiofibular ligament and interosseus ligament with clear widening of the tibiofibular joint and should be performed when one encounters these injuries, as we now routinely perform following the review of our experience. 487177 FAIXXX10.1177/1071100713487177Foot & Ankle InternationalResponse research-article2013