Jeffrey E. McAlister

Retrograde Intramedullary Nail With Femoral Head Allograft for Large Deficit Tibiotalocalcaneal Arthrodesis

Background: Large bone defects present a difficult task for surgeons when performing single-stage, complex combined hindfoot and ankle reconstruction. There exist little data in a case series format to evaluate the use of frozen femoral head allograft during tibiotalocalcaneal arthrodesis in various populations in the literature. Methods: The authors evaluated 25 patients from 2003 to 2011 who required a femoral head allograft and an intramedullary nail. The average time of final follow-up visit was 83 ± 63.6 weeks (range, 10-265). Results: Twelve patients healed the fusion (48%). Twenty-one patients resulted in a braceable limb (84%). Four patients resulted in major amputation (16%). Conclusion: This series may allow surgeons to more accurately predict the success and clinical outcome of these challenging cases. Level of Evidence: Level IV, case series.

The Direct Plantar Plate Repair Technique

Lesser metatarsophalangeal (MTP) joint instability is a common and painful condition that can severely limit activity and recreation. Synovitis and joint effusion may be seen early on with progression of instability to encompass predislocation and eventual complete dislocation of the MTP joint. Various surgical techniques have been described to treat lesser MTP joint instability and associated hammertoe deformities. Many surgeons experience frustration with the surgical outcome of metatarsal osteotomies and flexor transfers commonly used for this condition. The plantar plate apparatus is felt to be at the heart of the pathomechanics of this condition in many instances and is often misunderstood or even overlooked. Indirect dorsal approaches to plantar plate repair often require reliance on complex instrumentation and provide a limited view of the involved structures. The authors describe a direct plantar approach technique for plantar plate repair with realignment of the lesser MTP joint and hammertoe pathologies. Level of Evidence: V

Enhanced Lapidus Arthrodesis: Crossed Screw Technique With Middle Cuneiform Fixation Further Reduces Sagittal Mobility

Persistent medial column sagittal mobility can be encountered despite successful first tarsometatarsal stabilization if fixation has been limited to the first tarsometatarsal joint. The purpose of the present cadaveric research was to quantify the effect of a third point of fixation from the base of the first metatarsal to the middle cuneiform compared with the traditional isolated first tarsometatarsal fixation. Ten matched pairs of below-the-knee specimens, with a known cause of death, sex, ethnicity, and age, height, weight, and body mass index at death, were used for our examination. Portable fluoroscopy aided with the accurate placement of all points of fixation. Measurements of movement were obtained using the validated Klaue device. The 20 matched below-the-knee specimens were from 10 cadavers (2 female and 8 male donors, aged 72.8 ± 9.3 years, body mass index 21.1 ± 4.2 kg/m(2)). The sagittal plane motion of the first ray was 7.45 ± 1.82 mm before fixation. With isolated first tarsometatarsal fixation, the sagittal motion decreased to 4.41 ± 1.51 mm and decreased further to 3.12 ± 1.06 mm, with the addition of middle cuneiform fixation. Statistically significant enhancement of the stability of sagittal first ray motion was noted with the addition of the first metatarsal to middle cuneiform pin, even after simulated Lapidus fixation. Our findings suggest that first metatarsal to middle cuneiform fixation can be beneficial if excessive sagittal motion is present after standard 2-point fixation and can play a role in the prevention of recurrence and complications.

Symptomatic Hardware Removal After First Tarsometatarsal Arthrodesis

Severe hallux valgus deformity with proximal instability creates pain and deformity in the forefoot. First tarsometatarsal joint arthrodesis is performed to reduce the intermetatarsal angle and stabilize the joint. Dorsomedial locking plate fixation with adjunctive lag screw fixation is used because of its superior construct strength and healing rate. Despite this, questions remain regarding whether this hardware is more prominent and more likely to need removal. The purpose of the present study was to determine the incidence of symptomatic hardware at the first tarsometatarsal joint and to determine the incidence of hardware removal resulting from prominence and/or discomfort. A review of 165 medical records of consecutive patients who had undergone first tarsometatarsal joint arthrodesis with plate fixation was conducted. The outcome of interest was the incidence of symptomatic hardware removal in patients with clinical union. The mean age was 55 (range 18.4 to 78.8) years. The mean follow-up duration was 65.9 ± 34.0 (range 7.0 to 369.0) weeks. In our cohort, 25 patients (15.2%) had undergone hardware removed because of pain and irritation. Of these patients, 18 (72.0%) had a locking plate and lag screw removed, and 7 (28.0%) had crossing lag screws removed. The fixation of a first tarsometatarsal joint fusion poses a difficult situation owing to minimal soft tissue coverage and the inherent need for robust fixation to promote fusion. Hardware can become prominent postoperatively and can become painful and/or induce cutaneous compromise. The results of the present observational investigation imply that surgeons can reasonably inform patients that the incidence of symptomatic hardware removal after first tarsometatarsal arthrodesis is approximately 15% within a median duration of 9.0 months after surgery.

Bilateral Medial Foot Compartment Syndrome after an Aerobics Class: A Case Report

The authors present an unusual case of bilateral medial foot compartment syndrome in a healthy woman after a low-intensity aerobics exercise class. The majority of compartment syndrome cases have occurred after trauma, such as combat crush injuries and motor vehicle accidents. We wish to call attention to a rare situation in which compartment syndrome occurs in a healthy young adult after low-intensity exercise and highlight the necessity of a high clinical suspicion and a low threshold for fasciotomies to prevent irreversible muscle damage as a result of extremely high pressures. There is a paucity of cases on the clinical management and follow-up of this rare occurrence of compartment syndrome.

Surgical Planning for Flexor Digitorum Longus Tendon Transfers: An Anatomic Study

Abstract Posterior tibial tendon dysfunction is often coupled with various degrees of hindfoot valgus and equinus. Preoperative planning is essential to appropriate procedure choice and surgical efficiency. The purpose of the present study was to assess the anatomy at the harvest site for flexor digitorum longus tendon transfer, specifically at the master knot of Henry. Thirty fresh‐frozen below‐the‐knee cadavers were used for dissection. A standard anatomic approach was performed for posterior tibial tendon debridement and flexor digitorum longus tendon transfer. The flexor digitorum longus tendon was harvested and measured at the master knot of Henry. The present anatomic study evaluated the tendon width of the flexor digitorum longus tendon at a common harvest site. Of the 30 specimens, 20 (67%) measured 5 mm and 10 (33%) measured 4 mm. A 5.0‐mm interference screw would be acceptable in each specimen and therefore would be the safest choice. A 4.0‐mm interference screw would be acceptable in only 33% of the specimens. Males have a slightly more robust flexor digitorum longus tendon than females at the harvest site. This information will assist surgeons in preoperative planning during stage II flatfoot correction for posterior tibial tendon dysfunction. &NA; Level of Clinical Evidence: 5

Charcot-Marie-Tooth type 1A with a pes planovalgus foot type: a case report.

UNLABELLED The classic foot type of Charcot-Marie-Tooth type 1A is pes cavovarus with associated digital contractures. In this article, we describe a painful pes planovalgus foot type in a 10-year-old child with progressive Charcot-Marie-Tooth type 1A polyneuropathy. The authors discuss possible etiologies and treatment options in this isolated case. The value of gait analysis in preoperative planning and postoperative surveillance are also discussed. LEVEL OF CLINICAL EVIDENCE 4.

Allograft Bone: What Is the Role of Platelet-Derived Growth Factor in Hindfoot and Ankle Fusions

Arthrodesis of the ankle or foot is a common procedure for chronic pain and disability. Nonunion remains a prevalent complication among arthrodesis procedures. Some patients present with an inherent risk of developing a nonunion. Allograft biologics have gained popularity in an effort to reduce complications such as nonunion. Various biologics bring unique properties while maintaining a singular purpose. Platelet-derived growth factor (PDGF) may be introduced into a fusion site to facilitate healthy bony consolidation. The purpose of this article is to review the benefits and modalities of PDGF and how it can improve patient outcomes in ankle and hindfoot fusions.

Anatomic Description of the Naviculocuneiform Articulation

Abstract The naviculocuneiform articulation is composed of the navicular proximally and the 3 cuneiforms distally. It is not uncommon to perform surgical interventions at this joint for multiple pathologic foot etiologies. To date, no detailed anatomic measurement is available for each cuneiform articulation on the navicular. The purpose of the present study was to present an anatomic description of this complex joint to aid in better surgical understanding and improve surgical outcomes. Ten fresh, frozen, and thawed below‐the‐knee cadaveric specimens were used for anatomic dissection of the navicular and associated cuneiforms. The height and width were recorded across the largest span of the entire navicular–cuneiform joint complex and each facet. The mean navicular height and width was 19.9 mm and 34.7 mm, respectively. The medial cuneiform facet mean height and width was 19.9 mm and 15.8 mm, respectively. The intermediate cuneiform facet mean height and width was 20.4 mm and 16.9 mm, respectively. The lateral cuneiform facet mean height and width was 17.5 mm and 14.7 mm, respectively. A detailed description of this joint complex will aid foot and ankle surgeons in screw placement and surgical decision‐making when performing complex medial column fusions. Advanced 3‐dimensional weightbearing computed tomography would give us a better idea of the motion that occurs within this complex joint. &NA; Level of Clinical Evidence: 5

Distraction First Metatarsophalangeal Arthrodesis With Tricortical Calcaneus Autograft Technique Tips

First metatarsophalangeal joint arthritis can stem from a biomechanical imbalance as in hallux abducto valgus, metabolic arthritidies such as rheumatoid or gout, and even in posttraumatic cases. Advanced arthritis in the foot and ankle can often become debilitating. Surgical intervention is often necessary. Revision of failed first metatarsophalangeal joint arthroplasty is often in the setting of bony erosion and lysis, cystic changes, and loss of bone stock. In this article, we describe first metatarsophalangeal distraction arthrodesis technique using tricortical calcaneus autograft with the aim of simplifying donor site graft harvesting and decreasing donor site morbidity while attaining successful osseous union. Levels of Evidence: Level V