Justin M. Kane

The Epidemiology of Fifth Metatarsal Fracture.

Background. A paucity of data exists studying the epidemiology of fifth metatarsal fractures. While a number of studies exist focusing on specific fracture patterns and patient populations, a large comprehensive epidemiologic study on the general public does not. Objective. We reviewed 1275 fifth metatarsal fractures treated at a multicenter orthopaedic practice attempting to classify mechanism of injury and patient demographics as they pertain to specific fracture patterns. Methods. Patient demographics were recorded and fractures categorized by location and mechanism of injury. Demographics and mechanism of injury were assessed to determine their predictive value for the type of fracture. Statistical analysis was used to predict whether demographics and mechanism of injury were statistically significant for types of fractures and whether gender and age were positive predictive values for fifth metatarsal fractures. Results. Twisting injuries were a statistically significant predictor of zone 1 injuries. A significant correlation between gender and fracture location was seen with women sustaining 75% of zone 1 injuries and 84% of dancer’s fractures. A positive predictive value existed for age and gender with respect to the incidence of fractures. Males accounted for more fractures among younger patients and females accounting for the majority of fractures among older patients. Conclusion. Mechanism of injury is a predictor for fracture location. Gender and age have a role in fracture incidence. In younger patient populations, males account for the majority of fifth metatarsal fractures. In older patient populations, females account for the majority of fifth metatarsal fractures. Level of Evidence: Prognostic study, Level II: Retrospective Study

Addressing hindfoot arthritis with concomitant tibial malunion or nonunion with retrograde tibiotalocalcaneal nailing: a novel treatment approach.

BACKGROUND Tibial malunions and nonunions are associated with degenerative changes about the ankle. A comprehensive literature review revealed no articles discussing treatment options for patients with tibial shaft malunion and ipsilateral ankle arthritis. The aim of our study was to evaluate a series of patients in whom tibial osteotomy and retrograde tibiotalocalcaneal nailing were used to treat both tibial deformity and ankle osteoarthritis. METHODS Twenty-five patients underwent retrograde tibiotalocalcaneal nailing with concomitant realignment tibial osteotomy with takedown of the nonunion or malunion in a single procedure. All surgical procedures were performed by a single surgeon at a single institution. Baseline patient characteristics (age, sex, body mass index [BMI], preoperative diagnosis, and prior surgical procedures) were recorded. Data including visual analog scale (VAS) pain scores (0 to 10, with 0 indicating no pain and 10 indicating worst pain) and American Orthopaedic Foot & Ankle Society ankle-hindfoot (AOFAS-AH) scores were prospectively collected at the preoperative evaluation and the time of final follow-up, and patients were asked about their final satisfaction. Preoperative VAS scores averaged 8.3 (range, 7 to 10) of 10, which improved to an average of 2.8 (range, 0 to 6) at the time of final follow-up (p < 0.01). The preoperative AOFAS-AH scores averaged 43 (range, 18 to 62) of 100 and improved to 76 (range, 57 to 84) at the time of follow-up (p = 0.022). Twenty-one patients (84%) stated that they were extremely satisfied with the result of the procedure, three patients (12%) were satisfied, and one patient (4%) with a poor result was unsatisfied. CONCLUSIONS Tibial malunion or nonunion with concomitant hindfoot arthritis can be addressed with a single-stage procedure consisting of tibial osteotomy and retrograde intramedullary nailing for correction of the angular deformity and hindfoot fusion. This procedure provides a viable alternative to multiplanar external fixation or a staged procedure addressing the nonunion or angular deformity and the hindfoot arthritis separately.

Midterm Outcome of the Agility Total Ankle Arthroplasty

Background: Ankle arthritis is a debilitating condition that causes severe functional impairment. While arthrodesis has been the gold standard of surgical treatment for this condition, significant improvements in total ankle arthroplasty have made it a viable alternative. The purpose of this study was to look at the midterm follow-up of the Agility total ankle. Methods: A retrospective review of prospectively collected data was conducted on 127 consecutive Agility total ankles implanted between 2002 and 2009. Charts were reviewed to collect patient demographics. In addition, coronal alignment, overall arc of motion, tibiotalar component motion, syndesmotic fusion, zones of osteolysis, and subsidence were determined. A Kaplan-Meier survival and linear regression analysis were used to predict implant failure. A multivariate regression analysis was used to assess whether radiographic measures were predictive of patient satisfaction. Results: Ninety (78.2%) of 115 patients retained their primary implant, of which 105 were available for evaluation, with an average follow-up of 9.1 years. Twenty-five had their implant removed. The average score for the Foot and Ankle Ability Measure (FAAM) activities of daily living subscale was 82.4, FAAM sport subscale 55.3, postoperative visual analog scale (VAS) for pain 12.7, and Short Form-12 (SF-12) Health Survey physical component 45.8 and SF-12 mental component 56.1. Average arc of motion across the implant was 22.3 and 6.3 degrees in adjacent joints. Osteolysis most commonly occurred in zones 1 and 6. No statistical differences were found in the rate or location of subsidence. Linear regression analysis demonstrated that age at the time of surgery was predictive of failure (P = .036). Inflammatory and atraumatic arthritis demonstrated higher likelihoods of revision. No correlation was detected between radiographic parameters and outcomes scores (P > .05; rho >0.2). A significant reduction in mean VAS pain scores by 67.6% was maintained at an average of 8 years. Discussion: Our results were improved over the nondesigner outcomes published in the current literature. Survivorship approached 80% at 9 years, with Kaplan-Meier 14-year survival calculated at 70.4%. Patients with their original implant were functioning with a high level of satisfaction based on statistically validated outcome scores, which was independent of the radiographic appearance of their implant. Age at the time of surgery and inflammatory/atraumatic arthritis were predictive of failure. Level of Evidence: Level IV, case series.

Treatment of Catastrophic Infection After Surgery for Insertional Achilles Enthesopathy A Case Report and Review of the Literature

Wound complications after surgical treatment of insertional Achilles enthesopathy are well documented. Skin and tendon necroses pose a significant dilemma with the potential for catastrophic outcomes. Numerous treatment algorithms have been described to treat the resultant skin and tendon defects after catastrophic infection; however, to date, there is no consensus as to the optimal treatment modality. We report our experience in the management of deep infection of 2 patients who had previously undergone surgical treatment for insertional Achilles enthesopathy. A comprehensive review of the literature was undertaken with a focus on described treatment options. Levels of Evidence: Therapeutic, Level IV: Case report

Change in Angular Alignment is Associated With Early Dysphagia After Anterior Cervical Diskectomy and Fusion.

Study Design:Retrospective analysis of a prospective cohort. Objective:Change in cervical angular alignment may be associated with dysphagia. Summary of Background Data:Bony deformities of the cervical spine may be associated with secondary contractures of soft tissues in the neck. Acute surgical deformity correction causes in changes in soft tissue tension in the anterior neck, resulting in dysphagia. Methods:The study population included patients undergoing 1 and 2 level elective anterior cervical discectomy and fusion for cervical myelopathy or radiculopathy. Preoperative and postoperative radiographs at 2 weeks were measured by a blinded observer for C2–C7 endplate angle, C2–C7 posterior vertebral body length, and occipital condyle plumb line distance on upright lateral radiographs at 2, 6, and 12 weeks postoperatively. Patients were prospectively queried about dysphagia incidence and severity using a numeric rating scale. Multiple linear regression analysis was used to determine the effect of change in radiographic parameters controlling for demographic characteristics. Results:The study population included 25 patients with complete radiographs. The mean change in C2–C7 angle was −0.6 degrees (SD 9), the mean change in C2–C7 length was 1.7 mm (SD 26), the mean change in occipital condyle plumb line distance was 2.3 mm (SD 20).Multiple linear regression analysis was performed including operative time, age, sex, number of levels, and change in radiographic parameters as independent variables and using dysphagia score as the dependent variable. The change in C2–C7 angle and operative time were the only statistically significant predictors of change in dysphagia at 2 and 6 weeks postoperatively. Conclusions:These results indicate that lordotic change in spinal alignment and longer operative times are associated with increased postoperative dysphagia. Surgeons should counsel patients in whom a large angular correction is expected about the possibility for postoperative dysphagia. Furthermore, future studies on dysphagia incidence should include radiographic alignment as an independent predictor of dysphagia.

Rate of Neurologic Injury Following Lateralizing Calcaneal Osteotomy Performed Through a Medial Approach

Background: Calcaneal osteotomies are commonly used to correct varus hindfoot alignment in patients with symptomatic cavovarus deformity. Translational, closing wedge, and Malerba-type osteotomies have been implicated in the development of tarsal tunnel syndrome and neurologic injury to branches of the tibial nerve. The authors hypothesized that there would be minimal clinically important injury to the tibial nerve by performing a translational calcaneal osteotomy from a medial approach. Methods: All patients undergoing a cavovarus reconstruction by a single surgeon were identified. Patients were included if they underwent a lateralizing calcaneal osteotomy via medial approach. Demographics, operative reports, and clinic notes were reviewed to identify concomitant procedures performed, incidence of postoperative tarsal tunnel syndrome, complications, and preoperative and postoperative nerve examinations. Postoperative radiographs were reviewed for location of the osteotomy relative to the posterior tubercle. Results: Twenty-four patients underwent lateralizing calcaneal osteotomy via a medial approach. Of the osteotomies, 83.3% (20/24) were in the middle third of the calcaneus, with a mean of 11.6-mm translation. No patients developed postoperative tarsal tunnel syndrome or tibial nerve palsy. Conclusion: Lateralizing calcaneal osteotomy performed via a medial approach had a clinically negligible incidence of neurologic injury. Adequate translation was achieved to obtain correction of varus hindfoot deformity. The authors believe that there is less direct and less percussive injury to branches of the tibial nerve when performing the osteotomy from medial to lateral. This technique may represent an operative strategy to minimize risk to the tibial nerve and reduce neurologic deficit following cavovarus reconstruction. Level of Evidence: Level IV, case series.

The Efficacy of Platelet-Rich Plasma for Incision Healing After Total Ankle Replacement Using the Agility Total Ankle Replacement System

Background: The use of platelet-rich plasma (PRP) to aid in healing of operative incisions has been well documented in the literature. Most studies have been conducted retrospectively with small sample sizes and are conflicting in their outcomes. As such, no consensus exists regarding the utility of PRP for augmenting incisional healing. The Agility total ankle replacement (TAR) poses a significant challenge with respect to incisional healing in the immediate postoperative time frame and was used as a standardized implant in this study. We hypothesized that treating the anterior incision with PRP after Agility TAR would reduce the incidence of incision healing complications. Methods: A retrospective review of 133 consecutive Agility TAR performed by a single surgeon at a single institution was conducted. Platelet-rich plasma was used to augment incisional closure in 78 patients undergoing TAR. Fifty-five patients had incisional closure without PRP application. Incision healing complications were stratified into patients healing without any complications (none), patients requiring prolonged local wound care (minor), and patients requiring a return to the operation theater to address an incisional complication (major). Results: No statistically significant difference existed between patients treated with PRP incisional augmentation and those without PRP augmentation. Eight patients (10.3%) receiving PRP underwent operative treatment of an incisional complication, whereas 3 patients (5.5%) who had a nonaugmented closure required operative treatment (P = .52). The incidence of minor complications was not statistically significant, with 25 (32.1%) patients receiving PRP and 15 (27.3) patients who had a nonaugmented closure requiring prolonged local treatment (P = .85). Conclusions: Limited data exist regarding the use of PRP in the augmentation of the closure of operative incisions. We were unable to find a statistically significant reduction in incision-related complications in patients who had their incisions augmented with PRP. Level of Evidence: Level III, retrospective comparative study.

Surgical Tip A Minimally Invasive Mini Open Technique for Harvesting Iliac Crest Bone Graft

Level of Evidence: Level V, expert opinion.

Economic Analysis of Anatomic Plating Versus Tubular Plating for the Treatment of Fibula Fractures

Ankle fractures are among the most common injuries requiring operative management. Implant choices include one-third tubular plates and anatomically precontoured plates. Although cadaveric studies have not revealed biomechanical differences between various plate constructs, there are substantial cost differences. This study sought to characterize the economic implications of implant choice. A retrospective review was undertaken of 201 consecutive patients with operatively treated OTA type 44B and 44C ankles. A Nationwide Inpatient Sample query was performed to estimate the incidence of ankle fractures requiring fibular plating, and a Monte Carlo simulation was conducted with the estimated at-risk US population for associated plate-specific costs. The authors estimated an annual incidence of operatively treated ankle fractures in the United States of 59,029. The average cost was

Functional Outcomes of Peroneal Reconstruction with Peroneal Tendon Transfer

90.86 (95% confidence interval,