Joshua N. Tennant

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.

Patient Satisfaction Is Associated With Time With Provider But Not Clinic Wait Time Among Orthopedic Patients

Clinic wait time is considered an important predictor of patient satisfaction. The goal of this study was to determine whether patient satisfaction among orthopedic patients is associated with clinic wait time and time with the provider. The authors prospectively enrolled 182 patients at their outpatient orthopedic clinic. Clinic wait time was defined as the time between patient check-in and being seen by the surgeon. Time spent with the provider was defined as the total time the patient spent in the examination room with the surgeon. The Consumer Assessment of Healthcare Providers and Systems survey was used to measure patient satisfaction. Factors associated with increased patient satisfaction included patient age and increased time with the surgeon (P=.024 and P=.037, respectively), but not clinic wait time (P=.625). Perceived wait time was subject to a high level of error, and most patients did not accurately report whether they had been waiting longer than 15 minutes to see a provider until they had waited at least 60 minutes (P=.007). If the results of the current study are generalizable, time with the surgeon is associated with patient satisfaction in orthopedic clinics, but wait time is not. Further, the study findings showed that patients in this setting did not have an accurate perception of actual wait time, with many patients underestimating the time they waited to see a provider. Thus, a potential strategy for improving patient satisfaction is to spend more time with each patient, even at the expense of increased wait time. [Orthopedics. 2017; 40(1):43-48.].

Technical Tip and Cost Analysis for Lesser Toe Plantar Plate Repair With a Curved Suture Needle

The plantar plate is a thick ligamentous connection between the distal plantar metatarsal metaphyseal flare and the plantar base of the proximal phalanx. It has been recognized as the primary stabilizer of the metatarsophalangeal joint (MTP), and attenuation can lead to pain, instability, subluxation, and frank dislocation, including the eponymous “cross over toe” deformity. Insufficiency can result from acute traumatic tears but more commonly is the result of gradual degeneration, frequently associated with concomitant structural forefoot pathology including hammer or claw toe deformity or adjacent hallux valgus or rigidus. Tears tend to occur distally, and the second digit is most commonly affected. While most authors recommend conservative treatment before progressing to operative intervention, several operative techniques have been developed for recalcitrant cases. Initially, these involved tendon transfers and soft tissue releases, often used in conjunction. Synovectomy and osseous decompression were also described. Recurrence and continued pain were the most common complications seen after indirect repair techniques, and a cadaveric study suggested direct repair as a biomechanically viable alternative. These observations initially led to a technique utilizing a plantar approach for direct plantar plate repair or, in cases of more extensive damage, plantar plate transection with advancement and anchoring into the base of the proximal phalanx. Plantar repairs initially demonstrated good results when used in conjunction with tendon transfers and interphalangeal fusion. A dorsal approach for direct plantar plate repair subsequently gained attention as it has the potential to avoid painful plantar scars and allow access to adjacent MTPs through a single incision. Following a cadaveric study demonstrating its feasibility, multiple dorsal approach techniques were developed utilizing a metatarsal shortening osteotomy. At least 3 of these involve proprietary instruments to facilitate suture passage through the substance of the distal plantar plate. These facilitate efficient procedures and early data suggest good results, but the financial cost is substantial. The purpose of this article is to describe a technical modification to the dorsal approach to facilitate plantar plate repair without the relatively expensive proprietary instruments used for suture passage through the distal aspect of the plate and to analyze and discuss the potential associated cost reductions.

Disorders of the Flexor Hallucis Longus and Os Trigonum

Os trigonum syndrome with disease of the flexor hallucis longus tendon, so-called stenosing flexor tenosynovitis, is a common cause of posterior ankle impingement. Conservative treatment is the recommended first line of treatment, with secondary treatment options of either open or arthroscopic os trigonum excision with flexor hallucis longus retinaculum release. The arthroscopic approaches have gained popularity in the past decade because of less scarring, less postoperative pain, minimal overall morbidity, and earlier return to activities. However, comprehensive understanding of the anatomy of the posterior ankle is crucial to warrant successful outcomes and minimizing complications.

Bilateral anterior tarsal tunnel syndrome variant secondary to extensor hallucis brevis muscle hypertrophy in a ballet dancer: A case report

We present a case of bilateral anterior tarsal tunnel syndrome secondary EHB hypertrophy in a dancer, with successful treatment with bilateral EHB muscle excisions for decompression. The bilateral presentation of this case with the treatment of EHB muscle excision is the first of its type reported in the literature.

Cost effectiveness of the TriMed Sidewinder plate for the treatment of Weber B ankle fractures

Background:Ankle fractures are common injuries, and many have clear indications for operative treatment. Newer plate designs have recently been introduced and have the potential to simplify and shorten the operative procedure. This study compares the costs of operative treatment of a lateral malleolar fracture using a novel plate design or a neutralization plate and lag screw approach. Methods:A retrospective chart review was performed. All patients operatively treated for a Weber B lateral malleolar fracture were divided into two cohorts: an experimental group treated with a novel plate design and a control group treated with a lag screw and neutralization plate. Costs of implants, operating room costs and time to healing were compared between the two cohorts. Results:The average implant cost for the novel plate design (

Ankle Ligament Lesions

1141) was significantly higher than that of the plate and lag screw construct (

Management of Osteochondral Lesions of the Talar Dome

208; P<0.0001). The average operating room costs were significantly lower for the experimental group (

Cost and Cost-effectiveness Analysis of Treatment Options for Sanders II and III Calcaneus Fractures In Laborers.

4410) compared with the control group (

An Anatomic Study of the Percutaneous Endoscopically Assisted Calcaneal Osteotomy Technique to Correct Hindfoot Malalignment

6037; P<0.01). The average time to healing was significantly less in the experimental group (75 days) than in the control group (97 days; P<0.04). Conclusions:The decreased operating room costs likely resulted from attributes of the novel plate design that assist in fracture reduction and eliminate the need for a separate lag screw. The decreased dissection required to apply the novel plate could explain the quicker healing observed. The additional cost of new implant designs may be justified by quicker, simpler operative techniques and enhanced healing.