Lawrence A. Ford

Stabilization of the subluxed second metatarsophalangeal joint: Flexor tendon transfer versus primary repair of the plantar plate

Surgical treatment of the subluxed second metatarsophalangeal joint (MTPJ) has been a consistently frustrating problem for the foot and ankle surgeon. The plantar plate is the principal stabilizing structure of the second MTPJ and compromise to its integrity has been implicated as the cause of the subluxed second toe. Flexor tendon transfer has been reported as the mainstay of treatment to stabilize the subluxed second MTPJ. Recently, primary repair of the plantar plate has been advocated, yet no research exists comparing it to flexor tendon transfer. Eight freshly frozen lower extremity cadaver specimens were mounted on a custom-fabricated load frame. A vertical dorsally directed force was applied to the base of the proximal phalanx of the second toe via a pneumatic actuator to stimulate the Lachman test. Dorsal displacements of the proximal phalanx were measured with a linear variable distance transducer. This investigation examined the comparative strength of flexor tendon transfer versus primary repair of the plantar plate in stabilizing the second MTPJ. Results showed a significant difference between the transected plantar plate and the intact plantar plate. Displacements for the repair groups were similar to the intact plantar plate group and also significantly different from the transected plantar plate. Primary repair of the plantar plate is a viable alternative to flexor tendon transfer in stabilizing the second MTPJ with the advantage of addressing the pathology anatomically. Clinical studies are needed to substantiate these laboratory findings.

Rates of revision surgery using Chevron-Austin osteotomy, Lapidus arthrodesis, and closing base wedge osteotomy for correction of hallux valgus deformity.

To identify complications that necessitated revision surgery after the primary operation, a multicenter retrospective chart review was conducted for 646 patients who received either a modified chevron-Austin osteotomy (270 patients), modified Lapidus arthrodesis (342 patients), or closing base wedge osteotomy (34 patients) to correct hallux valgus deformity. Revision surgery for complications was calculated and compared. All surgery was performed by 1 of 5 staff foot and ankle surgeons at Kaiser Permanente medical centers. Complications included recurrent hallux valgus, iatrogenic hallux varus, painful retained hardware, nonunion, postoperative infection, and capital fragment dislocation. The rates of revision surgery after Lapidus arthrodesis, closing base wedge osteotomy and chevron-Austin osteotomy were similar with no statistical difference between them. The total rate for re-operation was 5.56% among patients who received chevron-Austin osteotomy, 8.82% among those who had a closing base wedge osteotomy, and 8.19% for patients who received modified Lapidus arthrodesis. Among patients who had the chevron-Austin osteotomy procedure, rates of re-operation were 1.85% for recurrent hallux valgus and 1.48% for hallux varus. Among patients who had the modified Lapidus arthrodesis, rates of re-operation were 2.92% for recurrent hallux valgus and 0.29% for hallux varus. Among patients who had the closing base wedge osteotomy, rates of reoperation were 2.94% for recurrent hallux valgus and 2.94% for hallux varus. The collected comparative complication rates should serve to provide adjunctive information for foot and ankle surgeons and patients regarding hallux valgus surgery.

Associated intra-articular ankle pathologies in patients with chronic lateral ankle instability: arthroscopic findings at the time of lateral ankle reconstruction.

Chronic lateral ankle instability (CLAI) can be a debilitating condition. The literature has shown that it is also associated with a number of intra-articular pathologies of the ankle. Some argue that if unaddressed, these intra-articular pathologies can predispose patients to osteoarthritis. Previous studies of patients who underwent prelateral stabilization ankle arthroscopy have shown a high number of pathologies, including osteochondral lesions of the talus. Purpose: The current study reviewed a consecutive series of patients diagnosed with CLAI who underwent ankle arthroscopy followed by a modified Brostrom-Gould procedure to validate the previous studies. Methods: Intraoperative reports on 28 ankles in 28 consecutive patients were reviewed from 2004 to 2008. Result: All 28 ankles (100%) demonstrated varying degrees of synovitis. Talar cartilage fibrillation was observed in 7 patients (25%), and talar dome cartilage defect was visualized in 4 patients (14%). Talar dome osteochondral defect was seen in 2 patients (7%), loose bodies were found in 3 patients (11%), Bassett’s lesion was seen in 2 patients (7%), and anterolateral impingement was seen in 4 patients (14%). Distal anterior tibial osteophytosis was seen in 4 patients (14%). Conclusion: This study confirms the high number of intra-articular pathologies in association with CLAI. Level of Evidence: Therapeutic, Level IV

Association between ankle fractures and obesity.

Obesity is an epidemic in the United States and is associated with an increased risk of musculoskeletal problems. Rotational injuries of the ankle with a Weber C fibula fracture have a greater risk of syndesmosis disruption and instability. The goal of the present study was to explore the association between obesity and ankle fractures. Using a retrospective review, the radiographs of 280 patients with an ankle fracture were reviewed and classified using the Weber classification, which was then associated with the body mass index, gender, age, diabetes, tobacco use, and osteoporosis. Patients with a body mass index of 30 kg/m(2) or greater (odds ratio 1.78), men (odds ratio 1.74), and age 25 years or younger (odds ratio 3.97) had greater odds of having a Weber C ankle fracture (compared with Weber A and B) and Weber C and B (compared with Weber A). Diabetes mellitus, osteoporosis/osteopenia, and current tobacco use were not significantly associated with the severity of the ankle fracture. The results from the present study suggest that obesity presents a greater risk of sustaining a more proximal distal fibula fracture.

Isolated Medial Incisional Approach to Subtalar and Talonavicular Arthrodesis

Triple arthrodesis is commonly used to correct complex deformity with hindfoot valgus. The authors use an isolated medial incisional approach for subtalar and talonavicular joint arthrodesis to correct hindfoot deformity, including high degrees of hindfoot valgus. To assess outcomes achieved with this approach, we reviewed the records of 45 patients from the practices of 5 surgeons. Independent variables evaluated included patient age, primary pathology, use of biologic agents, operative time, time to union, and complications. The median patient age was 57 years (range, 14-78 years). Pathology leading to fusion included 27 (60%) posterior tibial tendon dysfunction, 6 (13.3%) tarsal coalition, 7 (5.5%) degenerative joint disease, 2 (4.4%) rheumatoid arthritis, and 1 (2.2%) each, with Charcot neuroarthropathy, multiple sclerosis, and poliomyelitis. Orthobiological materials were used in 27 (60.0%) of the patients. The median duration of surgery was 87 minutes (range, 65-164 minutes), and the median time to successful arthrodesis was 8 weeks (range, 6-20 weeks). A complication was observed in 6 (13.3%) of the patients, including 1 each of the following: painful calcaneal-cuboid joint, talar fracture, incision dehiscence, poor exposure that required abandonment of the procedure, elevated first ray, and painful fixation. None of the patients experienced a nonunion or an adverse event related to the medial neurovascular structures. Based on our experience with the procedure, the single medial-incision subtalar and talonavicular joint arthrodesis is a useful alternative to triple arthrodesis for the correction of hindfoot valgus deformity.

First Metatarsophalangeal Joint Arthrodesis and Revision Arthrodesis

Arthrodesis of the first metatarsophalangeal joint is a powerful procedure that can improve the load-bearing capabilities of the forefoot and assist in medial arch stability. It is the mainstay of treatment for patients with severe arthritic deformity of the great toe joint, because it addresses the importance first ray weight-bearing has on the rest of the foot. In select individuals, fusion can also be effective as a primary procedure in the treatment of hallux valgus. Rather than cause detrimental effects to the function of the foot, this article suggests that first metatarsophalangeal arthrodesis can actually improve faulty mechanics secondary to a dysfunctional joint.

The Effect of the Lapidus Arthrodesis on the Medial Longitudinal Arch: A Radiographic Review

We reviewed the medical records and radiographs of 35 patients (3 males, 32 females; mean age 40.8 years) who underwent isolated, modified Lapidus arthrodesis for forefoot pathology in 39 feet. The purpose of the review was to evaluate the structural radiographic changes of the medial longitudinal arch (MLA) following isolated arthrodesis of the first tarsometatarsal joint. Pre- and postoperative standardized measurements of sagittal plane views of the foot were assessed to examine change in the MLA construct. The talo-first metatarsal angle and medial cuneiform height both had statistically significant changes, 2.97 degrees (range, 0-11.5 degrees) and 3.44 mm (range, 0-13 mm) (P < .0001) respectively. Our findings suggest that the Lapidus arthrodesis may influence the medial longitudinal arch.

External fixation of the foot and ankle. Elective indications and techniques for external fixation in the midfoot.

Although external fixation is widely used for treatment of fractures, limb deformities, and bone lengthening; use of external devices is still evolving. Elective cases for treatment of the midfoot and published research on external fixation specifically for surgical treatment of midfoot pain and deformity are scarce. Indications for elective external fixation in the midfoot are limited because rigid internal fixation in this area is relatively easy and successful. This article discusses podiatric conditions that can be treated advantageously by external fixation when elective surgery is done. The article also describes methods of external fixation appropriate for podiatric surgical reconstruction in patients with these conditions.

Arthroscopic Treatment of Ankle Osteochondral Lesions

Arthroscopic treatment of osteochondral lesions (OCLs) of the ankle is a popular first-line surgical option after conservative therapy has failed. MRI is the preferred imaging modality to evaluate OCLs and aid in surgical planning. Associated soft tissue pathology must be appreciated and addressed surgically, because associated synovitis and soft tissue impingement often contribute to symptoms. The diverse treatment modalities available via arthroscopy offer simplistic and straightforward solutions for biologically and mechanically complicated pathology. Marrow-stimulating techniques, particularly microfracture, have shown good to excellent results in most patients with small (<15 mm) acute lesions, and have a low complication rate.

Longitudinal Tear of the Tibialis Anterior Tendon

Diagnosis and treatment of longitudinal tears of the tibialis anterior tendon are not well documented in the surgical literature. Described here is successful primary surgical repair of a longitudinally torn tibialis anterior tendon in a 60-year-old woman.