John D. Maskill

Gastrocnemius Recession to Treat Isolated Foot Pain

Background: Gastrocnemius recession is performed to correct an isolated gastrocnemius equinus contracture of the ankle that may accompany foot and ankle pathology in the adult. It has been proposed that this equinus deformity leads to excessive strain throughout the foot, thus causing pain. This can manifest itself in the form of plantar fasciitis, metatarsalgia, posterior tibial tendon insufficiency, osteoarthritis, and foot ulcers. The purpose of this retrospective study was to review the efficacy of the gastrocnemius recession in providing pain relief for patients who have foot pain without structural abnormality who have failed conservative treatment and have an isolated gastrocnemius contracture. Materials and Methods: Twenty-nine patients (34 feet) who had chronic foot pain without any structural abnormality other than an isolated gastrocnemius contracture underwent a gastrocnemius recession and were available for follow up at an average of 19.5 (range, 7 to 44) months. The outcome measurements were related to pain relief (Visual Analog Scale) and patient satisfaction. Results: Preoperatively the average pain score was 8/10 which improved postoperatively to 2/10. Twenty-seven patients (93.1%) said they would recommend this procedure for isolated foot pain to a friend. Twenty-seven patients (93.1%) said they were satisfied with the results of the procedure. Twenty-three of 25 patients (92%) who had a unilateral procedure stated they would have the contralateral leg done if needed. Conclusion: Gastrocnemius recession was found to be an effective procedure when used to relieve recalcitrant foot pain in those patients with an isolated gastrocnemius contracture without deformity. Level of Evidence: IV, Retrospective Case Series

Surgical Management and Treatment Algorithm for the Subtle Cavovarus Foot

Background: Subtle cavovarus foot is a condition that can lead to significant foot pain and disability. We review the results of our treatment algorithm at medium-term followup. Materials and Methods: Thirty-five consecutive patients with lateral based symptoms due to an underlying congenital subtle cavovarus foot type were surgically corrected. Various procedures were utilized, including some combination of the following: lateral displacement calcaneus osteotomy, peroneus longus to brevis transfer, dorsiflexion first metatarsal osteotomy, and Achilles tendon lengthening. Twenty-three patients, with 29 feet, returned for followup examination. The mean patient age at the time of surgery was 43.4 years, and the mean followup to date was 4.4 years. Results: The mean AOFAS ankle hind-foot score preoperatively was 45, and postoperatively was 90. Radiographically, the medial cuneiform to floor height changed from 3.5 cm preoperatively to 3.0 cm postoperatively. The talo-first metatarsal angle improved 7.5 degrees postoperatively. There were no nonunions. No patients to date have gone on to fusions or revisions. Ten feet (34%) required hardware removal. All patients had resolution of their symptoms following hardware removal. Conclusion: The surgical management for the subtle cavovarus foot based on the proposed treatment algorithm provided symptomatic relief, longstanding correction, and high patient satisfaction. Level of Evidence: III, Case Control Study

Complications After Popliteal Block for Foot and Ankle Surgery

Background: A popliteal nerve block is a common analgesic procedure for patients undergoing surgery on their knee, foot, or ankle. This procedure carries less risk in a surgical setting compared with other forms of anesthesia such as a spinal block. Previous reports demonstrated few to no complications with the use of this nerve block, but it is unclear whether these data are consistent with the recent increase in use of this analgesic procedure for lower extremity surgery. Methods: Retrospectively, a busy orthopedic foot and ankle practice performed a chart review examining for postoperative neuropathic complications possibly related to the popliteal nerve block. The 1014 patients who had undergone a popliteal block for foot and/or ankle orthopedic surgery were analyzed for short and long-term neuropathic complications. The collected data consisted of tourniquet time, pressure, and location as well as the method of finding the fossa nerve, adjuncts used, and patient medical history. Data were analyzed using chi-square, Fisher’s exact, and t tests for analysis with a significance value of P < .05. Result: Of these 1014 patients, 52 patients (5%) developed deleterious symptoms likely resulting from their popliteal block, and 7 (0.7%) of these were unresolved after their last follow-up. No immediately apparent underlying causes were determined for these complications. Conclusion: The frequency of a neuropathic complication following a popliteal nerve block was notably higher in the early postoperative period than indicated in the past. The proportion of patients with unresolved neuropathic symptoms at last follow-up is comparable to that previously reported in the literature. Level of Evidence: Level IV, retrospective case series.

Tibial Compartment Syndrome and the Cavovarus Foot

Compartment syndrome of the leg is an orthopedic emergency that requires a high index of suspicion for diagnosis and a low threshold for surgical management to prevent devastating complications. Where the clinical findings are subtle, continuous monitoring of compartment pressures, with clinical correlation, is the key to diagnosis. Surgical management should include decompression of all four compartments and early rehabilitation to prevent ischemic contracture. If contracture develops, it may cause varying degrees of equinocavovarus deformity of the foot and ankle. Appropriate evaluation and careful surgical planning that considers all components of this complex deformity are essential for obtaining good clinical results.

Frequency and Impact of Adverse Events in Patients Undergoing Surgery for End-Stage Ankle Arthritis

Background: This study summarized the frequency and functional impact of adverse events (AEs) that occur after surgery for end-stage ankle arthritis (ESAA) to inform decision making. Methods: This was a multisite prospective cohort study to compare ankle arthroplasty to ankle arthrodesis in the treatment of ESAA among 6 participating sites. We compared the risk and impact of nonankle AEs and ankle-specific AEs versus no AEs controlling for potential confounding factors, including operative procedure using multinomial logistic regression. We estimated differences in postoperative functional outcomes by AE occurrence using linear mixed effects regression. Among 517 patients who had surgery for ankle arthritis and completed the full baseline assessment, follow-up scores were available in 494 (95%) patients. Results: There were a total of 628 reported AEs (477 in the arthroplasty group and 151 in the arthrodesis group). These occurred in 261 (63%) arthroplasty patients and 67 (65%) arthrodesis patients. There were 50 (8%) ankle-specific AEs. The risk of an ankle-specific AE was slightly higher in the arthrodesis group versus the arthroplasty group, odds ratio (OR) 1.84, 95% confidence interval (CI, 0.85, 3.98). The OR for the risk of non–ankle-specific AE versus no AE was 0.96, 95% CI (0.57, 1.61) for those receiving arthrodesis compared to arthroplasty. Compared to patients with no AEs, those experiencing ankle-specific AEs had significantly less improvement in Foot and Ankle Ability Measure Sports and activities of daily living (ADL) subscores and worst pain outcomes; however, both groups improved significantly in all measures except mental health. Conclusions: Ankle-specific AEs were infrequent and only weakly associated with operative procedure. Although patients improved in all functional outcomes except mental health, regardless of AE occurrence, ankle-specific AEs negatively impacted patient improvement compared to those with no AEs or a nonankle AE. The logistical effort and cost of tracking nonankle AEs does not seem to be justified. Level of Evidence: Level II, prospective comparative study.

Assessing Lateral Ankle Instability Following Modified Brostrom Procedure

Category: Ankle Introduction/Purpose: The modified Brostrom procedure obtained excellent to good results in 80% of patients treated for lateral ankle instability, making it one of the most common procedures for the treatment of this injury. In patients with a gastrocnemius contracture, however, the modified Brostrom repair leaves the narrower posterior talar dome held within the mortise. This decreased bony contact reduces stability and may be perceived by patients as continued instability post-operatively. The purpose of this study is to demonstrate that performing a gastrocnemius recession in conjunction with a modified Brostrom will increase the degree of stability of the ankle. This is the first study of its kind to our knowledge and hopes to further our knowledge of the functional improvements in the treatment of lateral ankle instability. Methods: This was a retrospective chart review with patients from the Orthopedic Associates of Michigan. 414 total patients in total with 82 who received gastrocnemius recession in conjunction with modified Bröstrom were evaluated for the purposes of this study. All patients were at least 14 years of age. Patients must have undergone a modified Brostrom procedure at a Spectrum Health or Metro Health facility from 1/1/2002 – 12/31/12 by performed Drs. Anderson, Bohay, or Maskill. Results: The mean age of all of the patients was 34.98 years (range 14-79). Pre-operatively, average AOFAS pain score for patients receiving modified Brostrom in isolation was 20.33, patients receiving concomitant gastrocnemius recession was 17.07. Post-operatively, average AOFAS pain score for patients receiving modified Brostrom in isolation was 32.29, patients receiving concomitant gastrocnemius recession was 32.44. Pre-operatively, proportion of patients meeting AOFAS stability criteria for those receiving modified Brostrom in isolation was 9.8%, those receiving concomitant gastrocnemius recession was 13.4%. Post- operatively, proportion of patients meeting AOFAS stability criteria for those receiving modified Brostrom in isolation was 76.8%, those receiving concomitant gastrocnemius recession was 86.6%. Conclusion: Patients receiving a concomitant gastrocnemius recession in addition to their modified Brostrom had increased pain pre-operatively but equivalent pain levels post-operatively compared to those who received a modified Brostrom in isolation. Additionally, there was a clinically significant increase in the percentage of patients with post-operative stability in those who received the gastrocnemius recession.

Early Weight Bearing Following First TMT Arthrodesis

Category: Midfoot/Forefoot Introduction/Purpose: The modified Lapidus arthrodesis is an accepted method of correcting varying degrees of hallux valgus with or without associated first ray insufficiency. Improved operative techniques have led to more reliable outcomes and lower incidence of nonunion. As a result, the modified Lapidus procedure has increased in popularity. Historically, surgeons have followed cautious postoperative protocols, initially restricting weight bearing until bone consolidation is confirmed radiographically. More recently, an alternative approach to postoperative management has been proposed, allowing patients to bear weight as tolerated two weeks after surgery with the goal of improving patient compliance while minimizing postoperative disability. The purpose of this study is to compare outcomes of patients randomized to either early weight bearing or standard non-weight bearing postoperative course following modified Lapidus arthrodesis. Methods: We determined that at least 130 patients would need to be enrolled in this study to achieve statistical significance (p < 0.05). Beginning in 2012, patients with hallux valgus indicated for modified Lapidus arthrodesis were assigned to either the investigational Group A (early weight bearing) or to the control Group B (standard of care) by a random number generator. All patients underwent modified Lapidus arthrodesis by one of the three senior authors (JGA, DRB, JDM). Specific demographic, clinical, patient-centered, and radiographic data were collected during the preoperative visit, the operative procedure, and at defined intervals during the postoperative period. The primary outcome variable was defined as first tarsometatarsal joint fusion at six months. Results: To date, 100 subjects have been enrolled, 57 of whom (40 patients in Group A, 17 patients in Group B) have completed one year of follow up. At six months, 38/40 patients in Group A had achieved radiographic union, compared to 17/17 patients in Group B (p = 0.495). Smoking status, BMI, and age at surgery were not found to be significantly associated with rate of union in either group. Patients in Group A required less time to reach full weight bearing status (p < 0.001). At six weeks after surgery, Group A reported significantly higher levels of physical function and overall composite scores on the SF-36 questionnaire. The rate of adverse events was not significantly different between the two groups at any postoperative timepoint. Conclusion: Though data collection is ongoing, our results indicate that clinical, patient-centered, and radiographic outcomes were comparable following modified Lapidus arthrodesis in both the early weight bearing and standard of care patient groups. Early weight bearing does not appear to increase the rate of adverse events or significantly slow rate of fusion, and also reduces postoperative disability.

An Eleven-Year Follow-up of a Custom Talar Prosthesis After Open Talar Extrusion in an Adolescent Patient

Talar extrusion is an extremely rare injury; isolated cases are reported in most instances1-8. Because of the paucity of literature pertaining to this injury, no definitive recommendations exist for treatment. General consensus among orthopaedic surgeons mandates that this injury be managed by thorough debridement of the wound and reduction of the extruded talus, if possible9. When complications like osteonecrosis and infection occur, the surgeon is left with few options outside of tibiocalcaneal arthrodesis. Often, this leaves the patient with a shortened limb and altered gait mechanics10. In 2007, Stevens et al. reported a talar extrusion in a fourteen-year-old girl who underwent an excision of the native talus because of infection, followed by replacement with a custom-made cobalt-chrome talar body prosthesis11. That case report was unique because of the age of the patient, the use of a metal implant in a previously infected wound, and the use of a custom-made metal prosthesis with a novel “snap-fit” design for purchase and stability. In this case report, we describe the same patient after eleven years of follow-up. The patient was informed that data concerning the case would be submitted for publication. A fourteen-year-old girl had been involved in a motor vehicle accident. On initial evaluation, there had been total extrusion of the right talus from a 10-cm lacerated wound on the lateral aspect of the ankle. The talus appeared intact but devoid of soft-tissue attachments, with the exception of a few capsular strands at the neck. The wound had been grossly contaminated with dirt and grass. The talus was reduced into the ankle joint in the operating room. The lateral ligaments of the ankle were reconstructed. The wound was left open and dressed under sterile conditions. The patient had debridements on days two, …