John E. Femino

Postoperative complications of posterior ankle and hindfoot arthroscopy.

BACKGROUND Posterior ankle and hindfoot arthroscopy, performed with use of posteromedial and posterolateral portals with the patient in the prone position, has been utilized for the treatment of various disorders. However, there is limited literature addressing the postoperative complications of this procedure. In this study, the postoperative complications in patients treated with posterior ankle and hindfoot arthroscopy were analyzed to determine the type, rate, and severity of complications. METHODS The study included 189 ankles in 186 patients (eighty-two male and 104 female; mean age, 37.1 ± 16.4 years). The minimum duration of follow-up was six months, and the mean was 17 ± 13 months. The most common preoperative intra-articular diagnoses were subtalar osteoarthritis (forty-six ankles), an osteochondral lesion of the talus (forty-two), posterior ankle impingement (thirty-four), ankle osteoarthritis (twenty), and subtalar coalition (five). The most common extra-articular diagnoses were painful os trigonum (forty-six), flexor hallucis longus tendinitis (thirty-two), and insertional Achilles tendinitis (five). RESULTS The most common intra-articular procedures were osteochondral lesion debridement (forty-four ankles), subtalar debridement (thirty-eight), subtalar fusion (thirty-three), ankle debridement (thirty), and partial talectomy (nine). The most common extra-articular procedures were os trigonum excision (forty-eight), tenolysis of the flexor hallucis longus tendon (thirty-eight), and endoscopic partial calcanectomy (five). Complications were noted following sixteen procedures (8.5%); four patients had plantar numbness, three had sural nerve dysesthesia, four had Achilles tendon tightness, two had complex regional pain syndrome, two had an infection, and one had a cyst at the posteromedial portal. One case of plantar numbness and one case of sural nerve dysesthesia failed to resolve. CONCLUSIONS Our experience demonstrated that posterior ankle and hindfoot arthroscopy can be performed with a low rate of major postoperative complications.

Diagnosis and treatment of acute Achilles tendon rupture.

This clinical practice guideline is based on a series of systematic reviews of published studies in the available literature on the diagnosis and treatment of acute Achilles tendon rupture. None of the 16 recommendations made by the work group was graded as strong; most are graded inconclusive; four are graded weak; two are graded as moderate strength; and two are consensus statements. The two moderate-strength recommendations include the suggestions for early postoperative protective weight bearing and for the use of protective devices that allow for postoperative mobilization.

Lisfranc Joint Displacement Following Sequential Ligament Sectioning

BACKGROUND There are two primary radiographic patterns of Lisfranc instability, transverse and longitudinal. There is no single diagnostic method with which to consistently confirm the diagnosis of an unstable injury. Our purpose was to define which ligament disruptions produce these two injury patterns and to compare the utility of weight-bearing and stress radiographs for detecting each pattern of instability. METHODS Ten fresh-frozen cadaveric lower extremities were dissected to expose the dorsal aspect of the midfoot. Radiographic markers were placed at the base of the second metatarsal and the distal borders of the first and second cuneiforms. The specimens underwent sectioning of the interosseous first cuneiform-second metatarsal (Lisfranc) ligament and were then divided into two groups. The transverse group underwent sectioning of the plantar ligament between the first cuneiform and the second and third metatarsals at the plantar aspect of the second cuneiform-second metatarsal joint, whereas the longitudinal group underwent sectioning of the interosseous ligament between the first and second cuneiforms. Weight-bearing, adduction, and abduction stress radiographs were made before and after each ligament was sectioned. The radiographs were digitized, and displacement was recorded. Instability was defined as >or=2 mm of displacement. RESULTS Weight-bearing radiographs made after the Lisfranc (first cuneiform-second metatarsal) ligament alone was sectioned were diagnostic (showed instability) for one of ten specimens. Abduction stress radiographs were diagnostic for two of five specimens, and adduction stress radiographs were diagnostic for zero of five specimens. In the transverse group (sectioning of the plantar ligament between the first cuneiform and the second and third metatarsals), weight-bearing radiographs were diagnostic on the basis of first cuneiform-second metatarsal displacement for one of five specimens but were not diagnostic on the basis of second cuneiform-second metatarsal displacement for any of five specimens. Abduction stress radiographs were diagnostic on the basis of displacement of both the first cuneiform-second metatarsal and the second cuneiform-second metatarsal joints for five of five specimens. In the longitudinal group (sectioning of the interosseous ligament between the first and second cuneiforms), weight-bearing radiographs were diagnostic on the basis of first cuneiform-second metatarsal displacement for one of five specimens and were diagnostic on the basis of displacement between the first and second cuneiforms for one of five specimens. Adduction stress radiographs were diagnostic on the basis of first cuneiform-second metatarsal displacement for one of five specimens and were diagnostic on the basis of displacement between the first and second cuneiforms for four of five specimens. CONCLUSIONS Transverse instability required sectioning of both the interosseous first cuneiform-second metatarsal ligament and the plantar ligament between the first cuneiform and the second and third metatarsals. Longitudinal instability required sectioning of both the interosseous first cuneiform-second metatarsal ligament and the interosseous ligament between the first and second cuneiforms. Compared with weight-bearing radiographs, injury-specific manual stress radiographs showed qualitatively greater displacement when used to evaluate both patterns of instability.

Sonography of Partial-Thickness Quadriceps Tendon Tears With Surgical Correlation

Objective. With the use of surgical findings as the reference standard, the purpose of this study was to describe the sonographic findings of partial‐thickness and complete tears of the quadriceps tendon and to determine whether sonography can potentially aid diagnosis. Methods. Three hundred eighty‐nine consecutive sonographic reports (January 1996 to April 2001) of the knee/quadriceps tendon were reviewed retrospectively and assessed for subsequent surgery on the quadriceps tendon. Seven cases were thus identified. Findings at surgery (complete versus partial tears) were compared with the original sonography reports. Results. All 4 partial tears and 1 of 2 complete tears were diagnosed correctly on the basis of sonography. One complete tear was described as a partial tear on the basis of sonography. In a seventh case, complete disruption of the extensor mechanism with osseous avulsion of the superior pole of the patella was identified correctly. Dynamic scanning was essential in diagnosing a partial quadriceps tendon tear in 1 case. Conclusions. Sonography, including the use of dynamic evaluation, was helpful in the diagnosis of partial‐thickness tears of the quadriceps tendon and may aid in differentiation of such cases from complete quadriceps tendon tears, particularly in the acute setting. The presence of scar tissue in the setting of chronic injury may represent a potential pitfall in the assessment of partial versus complete quadriceps tears. Further study is needed to define the accuracy of sonography for detecting quadriceps tendon tears.

The Effect of Suture-Button Fixation on Simulated Syndesmotic Malreduction: A Cadaveric Study

BACKGROUND The accuracy of reduction of distal tibiofibular syndesmosis disruptions has been associated with the clinical outcome. Suture-button fixation of the syndesmosis is a dynamic alternative mode of fixation. We hypothesized that with deliberate clamp-induced malreduction, suture-button fixation of the syndesmosis would allow a more anatomic post-fixation position compared with screw fixation. METHODS Forty-eight syndesmotic fixations were performed on twelve through-knee cadaveric specimens. The syndesmosis was destabilized and off-axis clamping was used to produce both anterior and posterior malreduction patterns. In twelve scenarios (six anterior and six posterior malreductions), syndesmotic screw fixation was used, followed by computed tomography. With tenacula holding the malreduction, the syndesmosis screws were exchanged for a suture-button construct and the specimens underwent a subsequent computed tomography scan. In the other twelve scenarios, the suture-button fixation was achieved first, followed by screw fixation. Standardized measurements of anterior-posterior and medial-lateral fibular displacement were performed by two observers blinded to the method of fixation. RESULTS With anterior off-axis clamping, the mean sagittal malreduction was 2.7 ± 2.0 mm with screw fixation and 1.0 ± 1.0 mm with suture-button fixation (p = 0.02). With posterior off-axis clamping, the sagittal malreduction was 7.2 ± 2.3 mm with screw fixation and 0.5 ± 1.4 mm with suture-button fixation (p < 0.01). No differences were observed between fixation types in the coronal plane (p = 0.20 for anterior malreductions and p = 0.06 for posterior malreductions). CONCLUSIONS With deliberate malreduction in a cadaver model, suture-button fixation of the syndesmosis results in less post-fixation displacement compared with screw fixation. The suture buttons ability to allow for natural correction of deliberate malreduction was greatest with posterior off-axis clamping. CLINICAL RELEVANCE Although the clinical relevance is unknown, dynamic syndesmotic fixation may mitigate clamp-induced malreduction.

Safe Zone for the Placement of Medial Malleolar Screws

BACKGROUND Hardware placement for fracture fixation can put soft-tissue structures at risk for injury or abutment. The prominence of the hardware is a frequent cause of pain after the fixation of ankle fractures. This study was designed to assess the risk of injury or abutment of the posterior tibial tendon with the placement of medial malleolar screws. METHODS Ten unmatched cadaveric limbs that had been disarticulated at the knee were used, and the medial malleolus was exposed by dissection of the skin. With use of fluoroscopy and direct visualization of the deep fascia, three Kirschner wires were placed through the tip of the medial malleolus and directed parallel to the medial articular surface. The first wire was placed in the center of the anterior colliculus. Two additional wires were placed parallel and posterior to the initial wire at 5-mm intervals. The wires were overdrilled, and 4.0-mm screws were inserted over the Kirschner wires. The specimens were dissected to inspect for trauma and the proximity of the screws to the posterior tibial tendon. The medial malleolus was divided into three zones on the basis of anatomic landmarks. Zone 1 is the anterior colliculus; Zone 2, the intercollicular groove; and Zone 3, the posterior colliculus. RESULTS Screws placed in Zone 1 (the anterior colliculus) did not contact the posterior tibial tendon in any specimens. Screws placed in Zone 2 (the intercollicular groove) were, on the average, 2 mm from the posterior tibial tendon. Screws placed in Zone 3 (the posterior colliculus) resulted in tendon abutment in all ten specimens and in tendon injury in five of the ten specimens. CONCLUSIONS Screws inserted posterior to the anterior colliculus place the posterior tibial tendon at significant risk for injury or abutment.

Complications of lesser toe surgery.

Surgical procedures for lesser toe problems are among the most common surgeries done on the foot. In a shoe wearing population, the incidence of lesser toe pathologic disorders is high. The complications associated with lesser toe surgery can be troublesome for patients and physicians. Understanding the possible common complications and how to avoid them is essential to maximizing satisfactory clinical results.

Risks to the blood supply of the talus with four methods of total ankle arthroplasty: a cadaveric injection study.

BACKGROUND Despite the use of contemporary total ankle arthroplasty implant designs, clinical outcomes of total ankle arthroplasty continue to lag behind those of other joint replacement procedures. Disruption of the extraosseous talar blood supply at the time of ankle replacement may be a factor contributing to talar component subsidence-a common mechanism of early failure following ankle replacement. We evaluated the risk of injury to specific extraosseous arteries supplying the talus associated with specific total ankle arthroplasty implants. METHODS Sixteen fresh-frozen through-knee cadaveric specimens were injected with latex and barium sulfate distal to the popliteal trifurcation to visualize the arteries. Four specimens each were prepared for implantation of four contemporary total ankle arthroplasty systems: Scandinavian Total Ankle Replacement (STAR), INBONE II, Salto Talaris, and Trabecular Metal Total Ankle (TMTA). Postoperative computed tomography scans and 6% sodium hypochlorite chemical debridement were used to examine, measure, and document the proximity of the total ankle arthroplasty instrumentation to the extraosseous talar blood supply. RESULTS All four implant types subjected the extraosseous talar blood supply to the risk of injury. The INBONE subtalar drill hole directly transected the artery of the tarsal canal in three of four specimens. The lateral approach for the TMTA transected the first perforator of the peroneal artery in two of four specimens. The STAR caused medial injury to the deltoid branches in all four specimens, whereas the other three systems did not directly affect this supply (p < 0.005). The Salto Talaris and STAR implants caused injury to the artery of the tarsal canal in one of four specimens. CONCLUSIONS All four total ankle arthroplasty systems tested posed a risk of injury to the extraosseous talar blood supply, but the risks of injury to specific arteries were higher for specific implants.

Tripod index: a new radiographic parameter assessing foot alignment.

Background: No single radiographic measurement takes into account complete foot alignment. We have created the Tripod Index (TI) to allow assessment of complex foot deformities using a standing anteroposterior (AP) radiograph of the foot. We hypothesized that TI would demonstrate good intraobserver and interobserver reliability and correlate with currently accepted radiographic parameters, in both flatfoot and cavovarus foot deformities. Methods: Three groups of patients were studied: 26 patients (30 feet) with flatfoot, 29 patients (30 feet) with cavovarus foot, and 51 patients (60 feet) without foot deformity as controls. Weight-bearing radiographs were obtained: foot AP with a hemispherical marker around the heel plus standard lateral and hindfoot alignment views. Radiographic measurements were made by 2 blinded investigators. Statistical analysis included intraclass correlation coefficients (ICCs), correlation of the TI with existing radiographic measurements using Pearson coefficients, and comparison between patient groups using analysis of variance. Results: Intraobserver and interobserver ICCs of TI (0.99 and 0.98, respectively) were excellent. In the flatfoot group, TI significantly correlated with AP talonavicular coverage angle (r = 0.43), medial cuneiform–fifth metatarsal height (r = -0.59), coronal plane hindfoot alignment (r = 0.53), and clinical hindfoot alignment (r = 0.39). In the cavovarus foot group, TI correlated significantly with AP talonavicular coverage angle (r = 0.77), calcaneal pitch angle (r = 0.39), medial cuneiform–fifth metatarsal height (r = -0.65), coronal plane hindfoot alignment (r = 0.55), and clinical hindfoot alignment (r = 0.61). Statistically significant differences between flatfoot-control and cavovarus foot–control were found in TI, AP talonavicular coverage angle, lateral talo–first metatarsal angle, calcaneal pitch angle, medial cuneiform–fifth metatarsal height, coronal plane hindfoot alignment, and clinical assessment of hindfoot alignment (all with P < .001). Conclusion: The TI was demonstrated to be a valid and reliable radiographic measurement to quantify the magnitude of complex foot deformities when evaluating flatfoot and cavovarus foot. Clinical Relevance: The TI may be helpful as an integrated assessment of complex foot deformities. Further clinical studies are recommended. Level of Evidence: Level III, retrospective comparative study.

Sonographic Evaluation of Lisfranc Ligament Injuries

Objective. This study characterized the sonographic appearances of Lisfranc injuries. Methods. Sonography reports (2000–2007) were searched for “Lisfranc,” resulting in 10 patients. Sonographic images of affected and asymptomatic contralateral feet were reviewed, recording the thickness of the dorsal ligament between the first (medial) cuneiform (C1) and second metatarsal (M2) ligaments, distance between C1 and M2, and change in this distance with weight bearing, hyperemia, and fractures. Correlations were made to clinical, surgical, and other imaging findings. Results. In 5 asymptomatic feet, the dorsal C1‐M2 ligament was 0.9 to 1.2 mm thick, and the C1‐M2 distance was 0.5 to 1 mm. Of the symptomatic feet, 1 group (n = 3) had normal sonographic findings (thickness, 0.9–1.1 mm; distance, 0.6–0.7 mm; all had normal radiographic findings and follow‐up, and 1 had normal magnetic resonance imaging [MRI] findings). Another group (n = 3) had abnormal hypoechogenicity and thickening of the dorsal C1‐M2 ligament (1.4–2.3 mm), a normal C1‐M2 distance (0.6–0.7 mm), and no widening with weight bearing (1 of 1), consistent with a ligament sprain (1 had normal computed tomographic [CT] findings, and all had uneventful follow‐up). The third group (n = 4) had nonvisualization of the dorsal C1‐M2 ligament, an increased C1‐M2 distance of 2.5 to 3.1 mm, and further widening with weight bearing (3 of 4) from Lisfranc ligament disruption (shown at surgery in 2, MRI in 1, and CT in 1). Conclusions. Nonvisualization of the dorsal C1‐M2 ligament and a C1‐M2 distance of 2.5 mm or greater were indirect signs of a Lisfranc ligament tear. Dynamic evaluation with weight bearing showed widening of the space between C1 and M2.