Joseph N. Daniel

The RAM Classification: A Novel, Systematic Approach to the Adult-Acquired Flatfoot

In summary, prior classifications have provided broad guidelines for treating the AAFF without accounting for case-specific variables in determining a treatment plan. The current system breaks down the deformity into three independent levels of involvement: the rearfoot, the ankle, and the midfoot. Via a simple, easy to remember, and reproducible schema based off the original Johnson and Strom classification, each level can be independently evaluated and a patient-specific surgical treatment plan can be formulated based on our most current understanding of the AAFF.

Recurrence of Hallux Valgus: A Review

Recurrence of hallux valgus deformity can be a common complication after corrective surgery. The cause of recurrent hallux valgus is usually multifactorial, and includes patient-related factors such as preoperative anatomic predisposition, medical comorbidities, compliance with postcorrection instructions, and surgical factors such as choice of the appropriate procedure and technical competency. For a successful outcome, this cause must be ascertained preoperatively. Although the algorithm to determine which intervention should be used is not unlike that of primary hallux valgus surgery, operative correction of hallux valgus recurrence can be challenging. This article discusses these challenges, complications, causes, and techniques.

Diagnosis and Management of Plantar Fasciitis

Plantar fasciitis, a chronic degenerative process that causes medial plantar heel pain, is responsible for approximately 1 million physician visits each year. Individuals with plantar fasciitis experience pain that is most intense during their first few steps of the day or after prolonged standing. The authors provide an overview of the diagnosis and management of a common problem encountered in the primary care setting. Routine imaging is not initially recommended for the evaluation of plantar fasciitis but may be required to rule out other pathologic conditions. Overall, plantar fasciitis carries a good prognosis when patients use a combination of several conservative treatment modalities. Occasionally, referral to a specialist may be necessary.

Driving After Hallux Valgus Surgery

Background: The purpose of the study was to determine when patients can safely return to driving after first metatarsal osteotomy for hallux valgus correction. Methods: After institutional review board approval, 60 patients undergoing right first metatarsal osteotomy for hallux valgus correction surgery were recruited prospectively. Patients’ brake reaction time (BRT) was tested at 6 weeks and repeated until patients achieved a passing BRT. A control group of twenty healthy patients was used to establish as passing BRT. Patients were given a novel driver readiness survey to complete. Results: At 6 weeks, 51 of the 60 patients (85%) had BRT less than 0.85 seconds and were considered safe to drive. At 6 weeks, the passing group average was 0.64 seconds. At the 8 weeks, 59 patients (100%) of those who completed the study achieved a passing BRT. Patients that failed at 6 weeks had statistically greater visual analog scale (VAS) pain score and diminished first metatarsophalangeal (MTP) range of motion (ROM). On the novel driver readiness survey, 8 of the 9 patients (89%) who did not pass disagreed or strongly disagreed with the statement, “Based on what I think my braking reaction time is, I think that I am ready to drive.” Conclusion: Most patients may be informed that they can safely return to driving 8 weeks after right metatarsal osteotomy for hallux valgus correction. Some patients may be eligible to return to driving sooner depending on their VAS, first MTP ROM, and driver readiness survey results. Level of Evidence: Level II, comparative study

Tibialis Anterior Tendon Reconstruction Using Augmented Half-Thickness Tendon Segment Transposition

Tibialis anterior tendon rupture causes substantial morbidity. The present study describes the outcomes of augmented, half-thickness tibialis anterior tendon segment transposition, a novel reconstruction technique. This was an institutional review board–approved retrospective review of 3 patients with surgically treated attritional distal rupture with 1-year follow-up. The postdebridement tendon defect prohibited primary repair and was managed by distal transposition of a half-thickness healthy segment. This repair was augmented with human acellular dermal matrix allograft (Graftjacket, Wright Medical Technology, Memphis, TN). The mean age was 68 years (range, 59-73 years). Mean interval between injury and surgery was 59.3 days (range, 15-146 days). All patients regained symmetrical range of motion, motor power, and the ability to heel walk. Mean pain scores improved from 4.6 (range, 2.5-8.5) preoperatively to 0.7 (range, 0-2) postoperatively. Mean Foot and Ankle Ability Measure scores increased from 30.6 (range, 23.8-43.8) preoperatively to 78.7 (range, 72.6-97.6) postoperatively. No postoperative complications occurred. One patient was satisfied and 2 were very satisfied with their outcome. Although limited, the present findings appear to indicate that this technique produces short-term clinical results comparable to those described for other techniques for tibialis anterior tendon reconstruction. Levels of Evidence: Therapeutic, Level IV

Predicting Failure of Nonoperative Treatment for Insertional Achilles Tendinosis

Nonoperative treatment for midportion Achilles tendinosis is well defined by the literature. Multiple modalities are described for the management of insertional Achilles pathology, but no consensus exists regarding efficacy. Surgical intervention for insertional Achilles tendinosis (IAT) is successful greater than 80% of the time. Our objective was to risk stratify patients who would fail nonsurgical management of IAT and thus benefit progressing to surgery. We reviewed the records of 664 patients with IAT. The cohort was 53% male and 80% obese. Mean age was 53.7 years (standard deviation 14.7 years). Average duration of symptoms was 10.4 months (standard deviation 28 months). Of the parameters collected, 4 were found to correlate with failing nonoperative treatment: visual analog scale, limited ankle range of motion, previous corticosteroid injection, and presence of Achilles tendon enthesophyte. We found that as the number of risk factors increased so did the chance of failing nonoperative treatment. With all 4 parameters, chance of failing conservative treatment was only 55%. Thus, nonoperative management should be exhausted until surgery is the only remaining option. However, the presence of one of the aforementioned risk factors can aid a surgeon in the decision to pursue surgery in the appropriate clinical scenario. Levels of Evidence: Level IV: Retrospective Case series

High Prevalence of Obesity and Female Gender Among Patients With Concomitant Tibialis Posterior Tendonitis and Plantar Fasciitis

The link between increased body weight and hindfoot complaints is largely based on correlation to single foot pathology. We retrospectively reviewed 6879 patients with tibialis posterior tendonitis (TPT), plantar fasciitis (PF), or both. Among patients with either TPT or PF, 1 in 11 (9%) had both. We then compared age, gender, and body mass index among these groups. Patients with both diagnoses were neither statistically older nor more obese than patients with single diagnoses. However, they were statistically more female. Given the overall high prevalence of obesity in the study population, we feel these data support the link between obesity and multiple foot pathology. Levels of Evidence: Prognostic, Level IV: Case series

Repair of Acute Extensor Hallucis Longus Tendon Injuries A Retrospective Review

Background. Extensor hallucis longus (EHL) tendon injuries may occur with lacerations sustained over the dorsum of the foot and lead to hallux dysfunction. Primary repair is performed when tendon edges are opposable; however, if a gap exists between tendon edges, then reconstruction with tendon graft or tendon transfer may be necessary to restore hallux alignment and dorsiflexion. We describe the surgical technique and report the results on a large series of patients having undergone primary repair or reconstruction of EHL tendon lacerations. Methods. We retrospectively reviewed all patients undergoing EHL tendon repair or reconstruction between January 2005 and May 2012. Information on patient demographics, mechanism of injury, time to surgery, intraoperative findings, surgical repair or reconstruction technique, and postoperative function were collected. Patients were contacted by telephone for administration of the Foot and Ankle Ability Measure (FAAM) and American Orthopaedic Foot and Ankle Society Hallux questionnaires. Results. Twenty of 23 patients undergoing EHL tendon repair or reconstruction were available for review at an average clinical follow-up of 12 months (range 3-89 months) and an average telephone follow-up of 5.1 years (range 1-10.4 years). Primary EHL repair was performed in 80% of cases, with the remaining patients undergoing reconstruction with deep tendon transfer of the extensor digitorum longus tendon from the second toe. At final follow-up, 19 of 20 patients had active hallux dorsiflexion. The average FAAM Activities of Daily Living score was 94.2% (range 58.3% to 100%) and the average FAAM Sports score was 94.2% (range 65.6% to 100%). Conclusion. Primary repair or reconstruction of EHL tendon lacerations is a reliable procedure that restores hallux alignment and function in most patients as measured by the validated FAAM questionnaire. Deep tendon transfer from the extensor digitorum longus may be performed if EHL tendon edges are not opposable thus eliminating the need for allograft reconstruction. Levels of Evidence: Therapeutic, Level IV, Case series

Spontaneous Fracture of the Os Peroneum With Rupture of the Peroneus Longus Tendon

Rupture of the peroneus longus tendon with or without an associated os peroneum fracture is rare and uncommonly encountered in the published data. Owing to the infrequent nature, a high index of suspicion is required. Otherwise, the opportunity for the injury to result in a delayed or missed diagnosis is increased. We report the case of a 39-year-old male with spontaneous rupture of the peroneus longus tendon and associated fracture of the os peroneum. The spontaneous rupture and fracture were diagnosed from the history, physical examination, and imaging findings. The patient elected to undergo operative repair, with excellent results, full recovery, and full return to normal function.

A Prospective Randomized Study Evaluating the Effect of Perioperative NSAIDs on Opioid Consumption and Pain Management After Ankle Fracture Surgery

Category: Trauma Introduction/Purpose: Currently there is an epidemic in the United States regarding opioid abuse. This has resulted in strict government prescribing regulations throughout the country and increasing efforts by orthopaedic surgeons to better manage postoperative narcotic analgesia. Non-steroidal anti-inflammatory drugs (NSAIDs) can serve as a powerful adjunct in managing postoperative pain and in turn minimize the need for opioid medications. It has recently been shown that ketorolac can be used after open reduction and internal fixation (ORIF) of ankle fractures without interfering with bone healing. Therefore, we set out to evaluate whether including ketorolac in the postoperative drug regimen reduces opioid consumption and pain after ORIF of ankle fractures. Methods: 128 patients undergoing ORIF of an ankle fracture were prospectively randomized to treatment with or without ketorolac. Patients also had the option to simultaneously undergo regional anesthesia. Patients assigned to the treatment group were given 30 mg of IV ketorolac intraoperatively; prescribed 20 tablets of ketorolac 10 mg PO Q6 H and 30 tablets of Oxycodone/Acetaminophen 5/325 Q4-6 H PRN. Patients assigned to the control group were given 30 tablets of oxycodone/acetaminophen 5/325 Q4-6 H PRN only. A survey was distributed via Research Electronic Data Capture (REDCap) on postoperative days 1-7. Patients were asked to report their daily opioid consumption, pain level using the Visual Analog Scale (VAS), satisfaction with pain management, and side effects. Intention-to-treat analysis was performed. Normality of data was tested using the Shapiro-Wilk test. Differences between the control and treatment groups were tested using Mann-Whitney U or Student’s t-tests. Results: 105/128 (82%) patients with mean BMI of 29.3 completed all study requirements. 54 received ketorolac with opioid medication and 51 received opioids alone. 43 men (41%) and 62 women (59%) participated with mean age of 48 years. Patients receiving ketorolac required less oxycodone/acetaminophen (p<0.013) and reported less pain (p<0.048) during postoperative days 1 and 2 compared to control patients(Figure 1). While opioid consumption did not significantly differ after day 2, patients treated with ketorolac maintained less pain (days 1-4, p<0.028); better sleep (days 1-5, p<0.037); lower frequency of pain (days 1-3; p<0.017); and greater satisfaction with pain management (days 1-3, p<0.047). Hypersensitivity was significantly less on day 1 (p=0.036) and paresthesias on day 3 (p=0.011). Surprisingly, there was no difference in nausea/constipation between groups (p>0.139). Conclusion: The addition of ketorolac to the postoperative drug regimen significantly reduced pain, while decreasing the use of opioid medication following ORIF of ankle fractures early in the postoperative period. Better pain management during postoperative days 1 and 2 is particularly important because patients on average consume the most opioids during this time. With the assurance that ketorolac does not interfere with bone healing, this NSAID is a valuable tool for helping patients manage postoperative pain with less narcotic analgesia.