Jorge I. Acevedo

Complications of Plantar Fascia Rupture Associated with Corticosteroid Injection

From 1992 to 1995, 765 patients with a clinical diagnosis of plantar fasciitis were evaluated by one of the authors. Fifty-one patients were diagnosed with plantar fascia rupture, and 44 of these ruptures were associated with corticosteroid injection. The authors injected 122 of the 765 patients, resulting in 12 of the 44 plantar fascia ruptures. Subjective and objective evaluations were conducted through chart and radiographic review. Thirty-nine of these patients were evaluated at an average 27-month follow-up. Thirty patients (68%) reported a sudden onset of tearing at the heel, and 14 (32%) had a gradual onset of symptoms. In most cases the original heel pain was relieved by rupture. However, these patients subsequently developed new problems including longitudinal arch strain, lateral and dorsal midfoot strain, lateral plantar nerve dysfunction, stress fracture, hammertoe deformity, swelling, and/or antalgia. All patients exhibited diminished tension of the plantar fascia upon examination by the stretch test. Comparison of calcaneal pitch angles in the affected and uninvolved foot showed a statistically significant difference of 3.7° (P = 0.0001). Treatment included NSAIDs, rest or cross-training, stretching, orthotics, and boot-brace immobilization. At an average 27-month follow-up, 50% had good/excellent scores and 50% had fair/poor scores. Recovery time was varied. Ten feet were asymptomatic by 6 months post rupture, four feet by 12 months post rupture, and 26 feet remained symptomatic 1 year post rupture. Our findings demonstrate that plantar fascia rupture after corticosteroid injection may result in long-term sequelae that are difficult to resolve.

Intramedullary rod fixation compared with blade-plate-and-screw fixation for tibiotalocalcaneal arthrodesis: a biomechanical investigation.

BACKGROUND Achieving stable fixation when performing tibiotalocalcaneal arthrodesis can be challenging, especially in osteopenic bone. The purpose of the current investigation was to compare the stiffness and fatigue endurance of blade-plate-and-screw fixation with intramedullary rod fixation in a cadaveric model. METHODS In ten matched pairs of fresh-frozen cadaveric legs, a tibiotalocalcaneal arthrodesis was performed with use of a blade-plate and a 6.5-mm sagittal screw in one leg and with use of an intramedullary rod in the contralateral leg. After an initial load-deformation curve was obtained, each specimen was loaded to 270 N through 250,000 cycles at a rate of 3 Hz. RESULTS Blade-plate-and-screw fixation resulted in significantly higher mean initial and final stiffness and decreased plastic deformation than did intramedullary rod fixation. In addition, there was an inverse correlation between bone-mineral density and the difference in plastic deformation noted between the specimens of each pair. CONCLUSIONS Blade-plate fixation is biomechanically superior to intramedullary fixation for tibiotalocalcaneal arthrodesis.

Arthroscopic Suture Anchor Repair of the Lateral Ligament Ankle Complex A Cadaveric Study

Background: Operative treatment of mechanical ankle instability is indicated for patients with multiple sprains and continued episodes of instability. Open repair of the lateral ankle ligaments involves exposure of the attenuated ligaments and advancement back to their anatomic insertions on the fibula using bone tunnels or suture implants. Hypothesis: Open and arthroscopic fixation are equal in strength to failure for anatomic Broström repair. Study Design: Controlled laboratory study. Methods: Seven matched pairs of human cadaveric ankle specimens were randomized into 2 groups of anatomic Broström repair: open or arthroscopic. The calcaneofibular ligament and anterior talofibular ligament were excised from their origin on the fibula. In the open repair group, 2 suture anchors were used to reattach the ligaments to their anatomic origins. In the arthroscopic repair group, identical suture anchors were used for repair via an arthroscopic technique. The ligaments were cyclically loaded 20 times and then tested to failure. Torque to failure, degrees to failure, initial stiffness, and working stiffness were measured. A matched-pair analysis was performed. Power analysis of 0.8 demonstrated that 7 pairs needed to show a difference of 30%, with a 15% standard error at a significance level of α = .05. Results: There was no difference in the degrees to failure, torque to failure, or stiffness for the repaired ligament complex. Nine of 14 specimens failed at the suture anchor. Conclusion: There is no statistical difference in strength or stiffness of a traditional open repair as compared with an arthroscopic anatomic repair of the lateral ligaments of the ankle. Clinical Relevance: An arthroscopic technique can be considered for lateral ligament stabilization in patients with mild to moderate mechanical instability.

Arthroscopic Lateral Ankle Ligament Reconstruction

The modified Brostrom repair is currently the method of choice for the primary operative treatment of chronic lateral ankle instability. Before 2007, the investigators used the traditional open approach with or without the use of suture anchors. This study describes our current technique for arthroscopic lateral ankle ligament reconstruction, which has been continuously refined over the past several years. We believe that this novel technique simplifies the ligament reconstruction procedure when performed with ankle arthroscopy, potentially reduces operative time, and will produce results equivalent to the long-term outcome of the traditional open Brostrom procedure. Since November 2007, twenty-three patients (24 ankles) have undergone arthroscopic lateral ligament repair. All patients had positive ankle instability with manual stress testing and failed nonoperative management. Initially, only one suture anchor was used for the technique and now all cases are performed with 2 anchors. After an average follow-up of 10.9 months, all patients reported significant improvement compared with their preoperative symptoms. Four patients were noted to a have mildly positive residual stress test despite no functional limitations. One patient had persistent peroneal tendon symptoms necessitating exploration and debridement; and 1 developed an unrelated neurological process. We describe our technique for arthroscopic lateral ankle ligament reconstruction and preliminary results.

Stability and fixation techniques in first metatarsal osteotomies.

Osteotomy of the first metatarsal is a common procedure for correction of hallucal disease. Metatarsals are unique in that they are the only long bones in the human body that support load perpendicular to their longitudinal axis during standing. Thus, osteotomy of the first metatarsal may be complicated by loss of fixation, resulting in nonunion or malunion. The authors review the forces that must be resisted by the osteotomy of the first metatarsal as postoperative weight bearing is initiated, and explore the principles of osteotomy geometry and different fixation techniques to maximize stability of the final construct and to minimize the risk of displacement.

Arthroscopic brostrom technique.

Surgical strategy regarding chronic lateral ankle instability is undergoing an evolution from traditional open procedures to minimally invasive and arthroscopic techniques. The development of arthroscopic techniques for the ankle mirrors the processes witnessed for the shoulder and knee over the last 30 years. The arthroscopic Brostrom is a novel technique that allows the surgeon to use an arthroscope to perform a lateral ankle ligament reconstruction that was previously thought possible only through open surgical technique. Indications and contraindications for the arthroscopic technique are essentially the same as those for an open Brostrom type of procedure. The arthroscopic Brostrom procedure is easy to remember and relatively simple to perform for the surgeon who has mastered basic ankle arthroscopy. The authors’ results discussed in this article reveal that the arthroscopic Brostrom is a safe and effective procedure with outcomes at least equal to published results for traditional open techniques. Level of Evidence: Level V, expert opinion.

ArthroBroström Lateral Ankle Stabilization Technique: An Anatomic Study.

Background: Arthroscopic ankle lateral ligament repair techniques have recently been developed and biomechanically as well as clinically validated. Although there has been 1 anatomic study relating suture and anchor proximity to anatomic structures, none has evaluated the ArthroBroström procedure. Purpose: To evaluate the proximity of anatomic structures for the ArthroBroström lateral ankle ligament stabilization technique and to define ideal landmarks and “safe zones” for this repair. Study Design: Descriptive laboratory study. Methods: Ten human cadaveric ankle specimens (5 matched pairs) were screened for the study. All specimens underwent arthroscopic lateral ligament repair according to the previously described ArthroBroström technique with 2 suture anchors in the fibula. Three cadaveric specimens were used to test the protocol, and 7 were dissected to determine the proximity of anatomic structures. Several distances were measured, including those of different anatomic structures to the suture knots, to determine the “safe zones.” Measurements were obtained by 2 separate observers, and statistical analysis was performed. Results: None of the specimens revealed entrapment by either of the suture knots of the critical anatomic structures, including the superficial peroneal nerve (SPN), sural nerve, peroneus tertius tendon, peroneus brevis tendon, or peroneus longus tendon. The internervous safe zone between the intermediate branch of the SPN and sural nerve was a mean of 51 mm (range, 39-64 mm). The intertendinous safe zone between the peroneus tertius and peroneus brevis was a mean of 43 mm (range, 37-49 mm). On average, a 20-mm (range, 8-36 mm) safe distance was maintained from the most medial suture to the intermediate branch of the SPN. The amount of inferior extensor retinaculum (IER) grasped by either suture knot varied from 0 to 12 mm, with 86% of repairs including the retinaculum. Conclusion: The results indicate that there is a relatively wide internervous and intertendinous safe zone when performing the ArthroBroström technique for lateral ankle stabilization. While none of the critical anatomic structures was entrapped by the suture knots, it was evident that the IER was included in a majority of the repairs. This study further defines the proximity of adjacent anatomic structures and establishes the anatomic safe zones for the ArthroBroström lateral ankle stabilization procedure. Clinical Relevance: By defining this relatively risk-free zone, surgeons who are not as experienced with arthroscopic lateral ligament repair techniques may approach arthroscopic suture passage with more confidence.

The Treatment of Unstable Ankle Fractures in Patients over Eighty Years of Age

Background: The current study examined the outcomes of operative treatment of unstable ankle fractures in patients at least 80 years old at the time of injury. Methods: Of 2,682 patients who presented for treatment of ankle fractures, 17 patients met the study criteria. These patients had open reduction and internal fixation after sustaining 15 closed and two open unstable ankle fractures. There were 11 type B fractures and six type C fractures by the Danis-Weber classification, and 12 supination-external rotation and five pronation-external rotation fractures by the Laugen-Hansen classification systems. Results: When noncompliant patients who developed complications were removed from analysis, the fixation failure and deep infection rates were 0% each. Conclusions: These results highlight the importance of patient compliance and nonweight-bearing status in the treatment of ankle fractures in patients over 80 years.

Biomechanical Analysis of an Arthroscopic Broström Ankle Ligament Repair and a Suture Anchor–Augmented Repair

Background: Secondary surgical repair of ankle ligaments is often indicated in cases of chronic lateral ankle instability. Recently, arthroscopic Broström techniques have been described, but biomechanical information is limited. The purpose of the present study was to analyze the biomechanical properties of an arthroscopic Broström repair and augmented repair with a proximally placed suture anchor. It was hypothesized that the arthroscopic Broström repairs would compare favorably to open techniques and that augmentation would increase the mean repair strength at time zero. Methods: Twenty (10 matched pairs) fresh-frozen foot and ankle cadaveric specimens were obtained. After sectioning of the lateral ankle ligaments, an arthroscopic Broström procedure was performed on each ankle using two 3.0-mm suture anchors with #0 braided polyethylene/polyester multifilament sutures. One specimen from each pair was augmented with a 2.9-mm suture anchor placed 3 cm proximal to the inferior tip of the lateral malleolus. Repairs were isolated and positioned in 20 degrees of inversion and 10 degrees of plantarflexion and loaded to failure using a dynamic tensile testing machine. Maximum load (N), stiffness (N/mm), and displacement at maximum load (mm) were recorded. Results: There were no significant differences between standard arthroscopic repairs and the augmented repairs for mean maximum load and stiffness (154.4 ± 60.3 N, 9.8 ± 2.6 N/mm vs 194.2 ± 157.7 N, 10.5 ± 4.7 N/mm, P = .222, P = .685). Conclusions: Repair augmentation did not confer a significantly higher mean strength or stiffness at time zero. Clinical Relevance: Mean strength and stiffness for the arthroscopic Broström repair compared favorably with previous similarly tested open repair and reconstruction methods, validating the clinical feasibility of an arthroscopic repair. However, augmentation with an additional proximal suture anchor did not significantly strengthen the repair.

Technique tip: avoiding wound complications after neglected Achilles tendon repair using a tissue expansion technique.

The Achilles tendon is the most commonly ruptured tendon in the human body.4 This is likely due in part to the increased popularity of endurance sports, such as running and jogging, that lead to chronic overuse of the tendon.7 Whether treatment by conservative or operative means is superior remains a controversial matter.8 Operative repair of Achilles tendon ruptures, especially neglected ones, poses a unique set of operative challenges for the surgeon.1 Many postoperative complications are associated with this surgery, including wound infection, seroma, sural nerve entrapment, fibrotic reaction, and re-rupture of the tendon.5 Most notable, however, is the high rate of wound complications.2,3,7 Achilles tendon surgery is associated with a higher rate of postoperative wound problems than most standard operative incisions.3 Postoperative complication rates are reported to be as high as 17% with most related to wound healing problems.2,7 Wounds smaller than 1 cm in size can lead to desiccation of the underlying tendon and secondary adhesions because of the relatively poor soft-tissue coverage over the superficial Achilles tendon.3,4 Paavola et al.7 reported that in 432 consecutive patients treated operatively for Achilles tendon rupture skin necrosis was the most common postoperative complication. Mitigating factors such as severe swelling and chronic inflammation have been noted to contribute to the poor wound healing in this relatively poorly vascularized area.3 Other factors inherent to repair of neglected ruptures can potentially lead to wound breakdown, including local skin contracture in the defective zone