Jeremy J. McCormick

Surgeon Practices regarding Operative Treatment of Posterior Malleolus Fractures

Background: Operative indications for surgical treatment of posterior malleolar fractures associated with fractures of the distal fibula and tibia are not currently well defined. The purpose of the present study was to determine the current practice among orthopaedic surgeons regarding the management of posterior malleolus fractures. Materials and Methods: Web-based questionnaires were emailed to members of the Orthopaedic Trauma Association (OTA) and American Orthopaedic Foot and Ankle Society (AOFAS). Requested information included demographics and treatment preferences for five clinical scenarios with different fracture characteristics. Four hundred one respondents completed the survey (20% response rate). Ninety eight (24%) subjects had received specialty training in orthopaedic trauma, 199 (50%) in foot and ankle (F&A) surgery and six (2%) in both orthopaedic trauma and F&A surgery. Ninety five (24%) had either no or other specialty training. Results: The most frequently reported indication for fixation was not based on a fragment size threshold, but rather was “depends on stability and other factors” (56%). Trauma surgeons, those with less than 10 years experience, and those who treated more than five ankles fractures per month were significantly more likely to use factors other than size for indications (p =0.026,<0.01, and <0.01, respectively). Despite this general response, fragment size still affected treatment decisions. A fragment comprising 50% of the articular surface was indicated for fixation by 97% of respondents, while a size of 10% would be treated by only 9% of respondents. For a posterior fragment with 20% articular involvement and a small free osteochondral fragment, fixation was deemed necessary by 44% of respondents. There were no differences in fellowship training, years of experience in practice, or ankle fracture volume per month in these three situations. A larger proportion of trauma trained surgeons considered fixation necessary compared to F&A trained surgeons in this case (p=0.028). When posterior malleolus fixation was indicated for a large fragment, direct open reduction using the flexor hallucis longus –peroneal tendon interval was the most commonly selected approach in all cases. Trauma-trained surgeons were significantly more likely to choose antiglide plate fixation compared to screw-only fixation (p <0.05). Conclusion: In this survey study of trauma and F&A surgeons, significant variation existed regarding most aspects of posterior malleolar ankle fracture treatment. Most notably, factors other than fragment size most impacted surgical indications. Newer techniques such as direct exposure and plating of the posterior malleolus are chosen more frequently than traditional techniques of indirect reduction and percutaneous screw fixation. Level of Evidence: IV, Cross-sectional Survey Study

Management of Common Sports-related Injuries About the Foot and Ankle

&NA; Foot and ankle injuries are commonplace in competitive sports. Improvements in injury surveillance programs and injury reporting have enabled physicians to better recognize and manage specific foot and ankle injuries, with a primary goal of efficient and safe return to play. Athletes are becoming stronger, faster, and better conditioned, and higher‐energy injuries are becoming increasingly common. Close attention is required during examination to accurately identify such injuries as turf toe, ankle injuries, tarsometatarsal (ie, Lisfranc) injuries, and stress fractures. Early diagnosis and management of these injuries are critical. Ultimately, however, pressure to return to play must not compromise appropriate care and long‐term outcomes.

The Great Toe: Failed Turf Toe, Chronic Turf Toe, and Complicated Sesamoid Injuries

Turf toe injuries and sesamoid injuries are challenging because of the variety of causes that exist as sources of pain. Through a systematic approach to evaluation, injuries to the hallux metatarsophalangeal joint can be diagnosed properly. Correct diagnosis leads to accurate and efficient treatment. If conservative measures fail, operative interventions are available to relieve pain and restore function. With careful surgical technique and appropriate postoperative management, athletes can return to play and efficiently reach their pre-injury level of participation.

Turf toe: anatomy, diagnosis, and treatment

Context: Despite an increasing awareness of turf toe injury, confusion still exists regarding the anatomy, mechanism, diagnosis, and treatment of this hyperextension injury to the hallux metatarsophalangeal (MTP) joint. Evidence Acquisition: This article reviews the anatomy, diagnosis, and treatment algorithm for turf toe injury by reviewing relevant studies and presenting information useful to clinicians, therapists, and athletic trainers. A literature search was performed by a review of PubMed and OVID articles published from 1976 to July 2010. Results: Grade I injury is a sprain or attenuation of the plantar capsular ligamentous complex of the hallux MTP joint; athletes are typically able to return to play as tolerated. Grade II injury is a partial rupture of the plantar soft tissue structures of the hallux MTP joint, typically requiring about 2 weeks to recover. Grade III injury is a complete rupture of the plantar structures of the hallux MTP joint, requiring at least 10 to 16 weeks to recover. Some complete ruptures require surgical repair. Conclusion: With accurate diagnosis, athletes can have an appropriate treatment plan, and their expectations can be tempered to the degree of injury. Careful management may allow successful return to play at a preinjury level of participation.

Intraosseous and Extraosseous Arterial Anatomy of the Adult Navicular

Background: The etiology of navicular stress fractures is a topic of interest due to the implications in high-level athletes. Previous studies suggest an avascular zone in the central one-third of the bone as a potential causative factor. This study investigated the extraosseous and intraosseous arterial anatomy of the adult navicular. Methods: Sixty legs from 30 cadavers were amputated below the knee. India Ink and Wards Blue Latex were injected into the anterior tibial, peroneal, and posterior tibial arteries. The specimens were frozen, thawed to room temperature, and the skin was sharply dissected away. The soft tissues were chemically debrided, leaving the bones, interosseous ligaments, and casts of the extraosseous blood vessels. The vascular supply to the navicular was elucidated in 55 specimens. The navicular was then cleared using a modified Spälteholz technique; the intraosseous vascularity was reviewed in 54 specimens. Results: Medial tarsal branches of the dorsalis pedis consistently supplied the dorsal navicular (96.4%). Lateral tarsal branches of varying size and distribution patterns also supplied the dorsal navicular. The medial plantar bone received small branches from the superficial branch of the medial plantar artery. Thirty of 54 specimens had a diffuse intraosseous vascular supply throughout the bone. Only six (11.8%) specimens had an avascular zone in the central third of the navicular extending to the dorsal cortex. Conclusion: The dorsalis pedis and posterior tibial arteries branch to supply blood flow to the navicular. In the majority of these specimens the navicular had a dense intraosseous vascular supply throughout it. Clinical Relevance: If diminished vascular supply is a contributing factor to navicular stress fracture, our results suggest that a relatively small proportion of individuals is prone to their development. Biomechanical or other clinical factors may play a more prominent role in the development of navicular stress fractures than previously suspected.

Vascular Anatomy of the Tibiofibular Syndesmosis

BACKGROUND Injuries to the tibiofibular syndesmosis commonly cause prolonged ankle pain and disability. Syndesmotic injuries are associated with slower healing rates compared with rates for other ankle ligament injuries and typically result in longer time away from sports. To our knowledge, the vascular supply to the syndesmosis and its clinical implication have not previously been studied. The purpose of this study was to describe the vascular supply to the tibiofibular syndesmosis with use of a method of chemical debridement of cadaveric specimens. METHODS Twenty-five matched pairs of adult cadaver legs, fifty legs total, were amputated below the knee. India ink, followed by Ward Blue Latex, was injected into the anterior tibial, peroneal, and posterior tibial arteries under constant manual pressure to elucidate the vascular supply of the ankle syndesmotic ligaments. Chemical debridement was performed with 6.0% sodium hypochlorite to remove soft tissue, leaving bones, ligaments, and casts of the vascular anatomy intact. The vascular supply to the syndesmosis was evaluated and recorded. RESULTS The anterior vascularity of the syndesmosis was clearly visualized in forty-three of fifty specimens. The peroneal artery supplied an anterior branch (the perforating branch) that perforated the interosseous membrane, an average of 3 cm proximal to the ankle joint. This branch provided the primary vascular supply to the anterior ligaments in twenty-seven specimens (63%). The anterior tibial artery provided additional contribution to the anterior ligaments in the remaining sixteen specimens (37%). CONCLUSIONS The location of the perforating branch of the peroneal artery places it at risk when injury to the syndesmosis extends to the interosseous membrane 3 cm proximal to the ankle joint. In the majority of specimens, injury to this vessel would result in loss of the primary blood supply to the anterior ligaments.

Medial Column Procedures in the Correction of Adult Acquired Flatfoot Deformity

AAFD is a complex problem with a wide variety of treatment options. No single procedure or group of procedures can be applied to all patients with AAFD because of the variety of underlying etiology and grades of deformity. As the posture of the foot progresses into hindfoot valgus and forefoot abduction through attenuation of the medial structures of the foot, the medial column begins to change shape. The first ray elevates and the joints of the medial column may begin to collapse. Careful physical examination and review of weight-bearing radiographs determines which patients have an associated forefoot varus deformity that may require correction at the time of flatfoot reconstruction. Correction of an AAFD requires a combination of soft-tissue procedures to restore dynamic inversion power and bony procedures to correct the hindfoot and midfoot malalignments. If after these corrections forefoot varus deformity remains, the surgeon should consider use of a medial column procedure to recreate the “triangle of support” of the foot that Cotton described.5 If the elevation of the medial column is identified to be at the first NC or the first TMT joint, then the joint should be carefully examined for evidence of instability, hypermobility, or arthritic change. If none of these problems exist, then the surgeon can consider use of the joint-sparing Cotton medial cuneiform osteotomy to correct residual forefoot varus. However, if instability, hypermobility, or arthritic change is present, then the surgeon should consider use of an arthrodesis of the involved joint to correct residual forefoot varus. Either procedure provides a safe and predictable correction to the medial column as part of a comprehensive surgical correction of AAFD.

Clinical presentation and self-reported patterns of pain and function in patients with plantar heel pain.

Background: Plantar heel pain is a common disorder of the foot. The purpose of this study was to explore the relationship between duration of symptoms in plantar fasciitis patients and demographic factors, the intensity and location of pain, extent of previous treatment, and self-reported pain and function. Methods: The charts of patients presenting with plantar heel pain between June 2008 and October 2010 were reviewed retrospectively and 182 patients with a primary diagnosis of plantar fasciitis were identified. Patients with symptoms less than 6 months were identified as acute and patients with symptoms greater than or equal to 6 months were defined as having chronic symptoms. Comparisons based on duration of symptoms were performed for age, gender, body mass index (BMI), comorbidities, pain location and intensity, and a functional score measured by the Foot and Ankle Ability Measure (FAAM). Results: The two groups were similar in age, BMI, gender, and comorbidities. Pain severity, as measured by a visual analog scale, was not statistically significant between the two groups (6.6 and 6.2). The acute and chronic groups of patients reported similar levels of function on both the activity of daily living (62 and 65) and sports (47 and 45) subscales of the FAAM. Patients in the chronic group were more likely to have seen more providers and tried more treatment options for this condition. Conclusion: As plantar fasciitis symptoms extend beyond 6 months, patients do not experience increasing pain intensity or functional limitation. No specific risk factors have been identified to indicate a risk of developing chronic symptoms. Level of Evidence: III, Retrospective Comparative Study

Precision of Foot Alignment Measures in Charcot Arthropathy

Background: Foot deformity associated with diabetes mellitus (DM) and peripheral neuropathy (PN) contributes to joint instability, ulceration and amputation. This study reports the intrarater and inter-rater measurement precision and least significant change (LSC) of radiological measures of foot deformity in subjects with DM, PN, and foot related complications. Methods: Cuboid height, Mearys angle, calcaneal pitch and hindfoot-forefoot angle were measured from plain-film radiographs on 15 subjects with DM, PN, and foot-related complications. A foot and ankle fellowship-trained orthopedic surgeon with 23 years of experience (Rater 1) measured radiographs twice. A foot and ankle fellowship-trained orthopedic surgeon with 2 years of experience (Rater 2) and a radiologist in residency training (Rater 3) measured radiographs once. Root mean square standard deviation and LSC were calculated to determine measurement precision and the smallest change considered biologically real, not the result of chance. Results: Intrarater measurement precision was: 0.9 mm for cuboid height, 3 degrees for Mearys angle, and 2 degrees for calcaneal pitch and hindfoot-forefoot angle. Inter-rater measurement precision for rater 1 versus 2 and 1 versus 3 were: 1.7 and 1.6 mm for cuboid height, 4 degrees for Mearys angle, 2 degrees for calcaneal pitch, and 3 degrees for the hindfoot-forefoot angle. The LSC was less than or equal to: 4.7 mm for cuboid, 12 degrees for Mearys angle, 6 degrees for calcaneal pitch, and 8 degrees for hindfoot-forefoot angle. Conclusion: Cuboid height, calcaneal pitch, and hindfoot-forefoot angle measures can be completed with relatively good measurement precision.

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