Manuel J. Pellegrini

Conversion of Tibiotalar Arthrodesis to Total Ankle Arthroplasty

BACKGROUND Conversion of ankle arthrodesis to total ankle arthroplasty remains controversial. Although satisfactory outcomes have been published, not all foot and ankle surgeons performing total ankle arthroplasty have embraced this modality. METHODS Twenty-three total ankle arthroplasties were performed in patients who had undergone a prior or an attempted ankle arthrodesis. The mean age at surgery was fifty-nine years (range, forty-one to eighty years), and the mean duration of follow-up was 33.1 months (minimum, twelve months). Indications for the procedure were symptomatic adjacent hindfoot arthritis (twelve patients) or symptomatic tibiotalar or subtalar nonunion (eleven) after tibiotalocalcaneal arthrodesis. We performed concomitant surgical procedures in eighteen ankles (78%), with the most common procedure being prophylactic malleolar fixation (70%). We prospectively evaluated clinical outcomes using the Short Form-36 (SF-36), Short Musculoskeletal Function Assessment (SMFA), and visual analog scale (VAS) for pain and assessed initial weight-bearing radiographs and those made at the most recent follow-up evaluation. RESULTS The mean VAS pain score (and standard deviation) improved from 65.7 ± 21.8 preoperatively to 18.3 ± 17.6 at the most recent follow-up evaluation (p < 0.001), with five patients being pain-free (VAS score = 0). The mean SMFA bother and function indexes improved from 55 ± 22.9 and 46.7 ± 12.6 preoperatively to 30.6 ± 22.7 and 25.4 ± 17.4 at the most recent follow-up visit (p = 0.001 and p < 0.001, respectively). The mean SF-36 total score improved from 37.7 ± 19.3 to 56.4 ± 23.1 (p = 0.002). The implant survival rate was 87%. Four (20%) of the tibial components and fourteen (70%) of the talar components that were not revised exhibited initial settling and then were seen to be stabilized radiographically without further change in implant position. Three total ankle replacements (13%) showed progressive talar subsidence, prompting revision. Ten patients (43%) had minor complications not requiring repeat surgery. CONCLUSIONS Short-term follow-up after conversion of ankle arthrodesis to total ankle arthroplasty demonstrated pain relief and improved function in a majority of patients. Patients who undergo this surgery frequently require concomitant procedures; we recommend prophylactic malleolar fixation when performing conversion total ankle arthroplasty. The rate of complications, particularly talar component settling and migration, is cause for concern. We do not recommend the procedure for ankle arthrodeses that included distal fibulectomy.

Outcomes of Tibiotalocalcaneal Arthrodesis Through a Posterior Achilles Tendon–Splitting Approach

Background: A number of operative approaches have been described to perform a tibiotalocalcaneal (TTC) arthrodesis. Here we present the largest reported series of a posterior Achilles tendon–splitting approach for TTC fusion. Methods: With institutional review board approval, a retrospective review of the TTC fusions performed at a single academic institution was carried out. Orthopedic surgeons specializing in foot and ankle surgery performed all procedures. Eligible patients included all those who underwent a TTC fusion via a posterior approach and had at least a 2-year follow-up. Forty-one patients underwent TTC arthrodesis through a posterior Achilles tendon–splitting approach. Mean age at surgery was 56.9±15.0 years. There were 21 female and 20 male patients. Preoperative diagnoses included arthritis (n = 13 patients), failed total ankle arthroplasty (9), avascular necrosis of the talus (9), prior nonunion of the ankle and/or subtalar joint (6), Charcot neuro-arthropathy (2), and stage IV flatfoot deformity (2). In 37 patients (90.2%), a hindfoot intramedullary arthrodesis nail was used, with posterior plate or supplemental screw augmentation in 17 patients. Posterior plate stabilization alone was utilized in 4 cases (9.8%). Results: The fusion rate was 80.4%. Eight patients developed a nonunion of the subtalar, tibiotalar, or both joints. Complications were observed in 17 patients (41.4%). Of these, ankle nonunion (19.5%), tibial stress fracture (17%), postoperative cellulitis and superficial wound breakdown (9.7%), subtalar nonunion (4.8%), and TTC malunion (2.4%) were the most frequently identified. One patient eventually underwent amputation (2.4%). Conclusion: We believe that posterior Achilles tendon–splitting approach for tibiotalocalcaneal arthrodesis was a safe and effective method, with similar union and complications rates to some previously described techniques. We believe the posterior approach is advantageous as it provides simultaneous access to both the ankle and subtalar joints and allows for dissection to occur between angiosomes, which may preserve blood supply to the skin. Level of Evidence: Level IV, retrospective case series.

Systematic Quantification of Stabilizing Effects of Subtalar Joint Soft-Tissue Constraints in a Novel Cadaveric Model

BACKGROUND Distinguishing between ankle instability and subtalar joint instability is challenging because the contributions of the subtalar joints soft-tissue constraints are poorly understood. This study quantified the effects on joint stability of systematic sectioning of these constraints followed by application of torsional and drawer loads simulating a manual clinical examination. METHODS Subtalar joint motion in response to carefully controlled inversion, eversion, internal rotation, and external rotation moments and multidirectional drawer forces was quantified in fresh-frozen cadaver limbs. Sequential measurements were obtained under axial load approximating a non-weight-bearing clinical setting with the foot in neutral, 10° of dorsiflexion, and 10° and 20° of plantar flexion. The contributions of the components of the inferior extensor retinaculum were documented after incremental sectioning. The calcaneofibular, cervical, and interosseous talocalcaneal ligaments were then sectioned sequentially, in two different orders, to produce five different ligament-insufficiency scenarios. RESULTS Incremental detachment of the components of the inferior extensor retinaculum had no effect on subtalar motion independent of foot position. Regardless of the subsequent ligament-sectioning order, significant motion increases relative to the intact condition occurred only after transection of the calcaneofibular ligament. Sectioning of this ligament produced increased inversion and external rotation, which was most evident with the foot dorsiflexed. CONCLUSIONS Calcaneofibular ligament disruption results in increases in subtalar inversion and external rotation that might be detectable during a manual examination. Insufficiency of other subtalar joint constraints may result in motion increases that are too subtle to be perceptible. CLINICAL RELEVANCE If calcaneofibular ligament insufficiency is established, its reconstruction or repair should receive priority over that of other ankle or subtalar periarticular soft-tissue structures.

Are locking plates better than non-locking plates for treating distal tibial fractures?

BACKGROUND Locking and non-locking plates has been used for distal tibia fracture osteosynthesis. Sufficient evidence to favor one implant over the other is lacking in the current literature. Our aim is to compare them in terms of fracture healing, alignment, functional outcome, complications. METHODS Sixty-eight patients operated on using a percutaneous plate were retrospectively reviewed. They were divided into two groups: in group 1 (28 patients) a 4.5mm narrow conventional dynamic compression plate (DCP) was used. In group 2 (40 patients) a titanium locked compression plate (LCP) was used. RESULTS Mean time to union was 16.2 and 15.4 weeks for group 1 and 2, respectively (p=0.618). 11 patients (39.3%) in group 1 and 4 patients (10%) in group 2 showed malalignment (p=0.016). AOFAS scores at follow up were 89 and 88 in groups 1 and 2, respectively. Implant removal was necessary in 9 cases (32.1%) and 4 cases (10%) in group 1 and group 2, respectively (p=0.042). Three patients (10.7%) in group 1 and three patients (7.5%) in group 2 had an infection. CONCLUSIONS Both plating systems have similar results in terms of time to union, infection, and AOFAS scores. The LCP seems superior with respect to alignment and the need for implant removal.

Reversal of Peroneal Tenodesis With Allograft Reconstruction of the Peroneus Brevis and Longus: Case Report and Surgical Technique.

Chronic peroneal tendinopathy and tears represent a challenging clinical situation. Traditionally, tenodesis of the torn tendon to the remaining healthy tendon has been advocated if more than half of the tendon is compromised. Allograft reconstructions have been reserved for patients with functional muscles and both peroneal tendons extensively compromised. We report a unique case of a peroneal tenodesis takedown and reconstruction of both peroneal tendons using semitendinosus allograft. A description of the surgical technique and tips are provided. Peroneal tendon function is crucial to maintain a balanced hindfoot. To the best of our knowledge, reconstruction of both peroneal tendons after a tenodesis has not been previously reported. Allograft reconstruction of the peroneal tendons arises as a feasible alternative in patients with residual pain and weakness after a failed tenodesis surgery Levels of Evidence: Therapeutic Level IV, case study

Tibiotalar Arthrodesis Conversion to Total Ankle Arthroplasty

Introduction Although conversion of the painful ankle arthrodesis to total ankle arthroplasty remains controversial, this surgical modality has satisfactorily expanded the treatment armamentarium for addressing this pathology. Indications & Contraindications Step 1 Preoperative Preparation and Surgical Planning Preoperative preparation and planning is similar to that for a primary total ankle arthroplasty, and implants designed for primary arthroplasty can be used in most patients managed with conversion to total ankle replacement. Step 2 Patient Positioning Position the patient as for a primary total ankle replacement. Step 3 Remove Hardware and Insert Prophylactic Malleolar Screws Preserve exsanguination time by removing hardware prior to inflating the tourniquet. Step 4 Recreate the Tibiotalar Joint Recreate the native joint line, which can be relatively easy in selected patients and challenging in others. Step 5 Set the Optimal Talar Slope Set the optimal talar slope, which can be challenging, particularly when the ankle arthrodesis is malunited in equinus. Step 6 Recreate the Medial and Lateral Gutters Because the former medial and lateral articulations between the talus and the malleoli can be difficult to define, use careful surgical technique to avoid compromise of the malleoli and excessive talar resection. Step 7 Mobilize the Ankle and Use Bone Graft in Defects from Previous Hardware To avoid potential malleolar fractures, mobilize the ankle only after the prophylactic malleolar screws have been placed; the tibial and talar cuts, completed; the gutters, reestablished; all resected bone, removed; and scar tissue from the posterior aspect of the ankle, excised; thereafter, conversion total ankle arthroplasty is similar to a primary total ankle replacement, with the exception of potential bone defects where prior hardware was positioned. Step 8 Talar Preparation Perform the routine steps for primary total ankle arthroplasty, often ignoring bone defects from the ankle arthrodesis hardware, but plan to repair the defects with bone-grafting before implanting the final talar component. Step 9 Tibial Preparation and Definitive Components Perform tibial preparation in a manner similar to that used for primary total ankle arthroplasty. Results We performed 23 conversion total ankle arthroplasties in patients who had an ankle arthrodesis, including those with pain despite successful fusion and those with painful nonunions9. Pitfalls & Challenges

Effectiveness of Allograft Reconstruction vs Tenodesis for Irreparable Peroneus Brevis Tears A Cadaveric Model

Background: Irreparable peroneus brevis tendon tears are uncommon, and there is scant evidence on which to base operative treatment. Options include tendon transfer, segmental resection with tenodesis to the peroneus longus tendon, and allograft reconstruction. However, the relative effectiveness of the latter 2 procedures in restoring peroneus brevis function has not been established. Methods: Custom-made strain gage–based tension transducers were implanted into the peroneus longus and brevis tendons near their distal insertions in 10 fresh-frozen cadaver feet. Axial load was applied to the foot, and the peroneal tendons and antagonistic tibialis anterior and posterior tendons were tensioned to 50% and 100% of physiologic load. Distal tendon tension was recorded in this normal condition and after sequential peroneus brevis-to-longus tenodesis and peroneus brevis allograft reconstruction. Measurements were made in 5 foot inversion/eversion and plantarflexion/dorsiflexion positions. Results: Distal peroneus brevis tendon tension after allograft reconstruction significantly exceeded that measured after tenodesis in all tested loading conditions (P ≤ 0.022). With 50% of physiologic load applied, peroneus brevis tension was 1% to 28% of normal (depending on foot position) after tenodesis and 73% to 101% of normal after allograft reconstruction. Under the 100% loading condition, peroneus brevis tension was 6% to 43% of normal after tenodesis and 88% to 99% of normal after reconstruction with allograft. Distal peroneus longus tension remained within 20% of normal under all operative and loading conditions. Conclusion: Allograft reconstruction of a peroneus brevis tendon tear in this model substantially restored distal tension when the peroneal tendons and their antagonists were loaded to 50% and 100% of physiologic load. Tenodesis to the peroneus longus tendon did not effectively restore peroneus brevis tension under the tested conditions. Clinical Relevance: Because tenodesis was demonstrated to be ineffective for restoration of peroneus brevis function, this procedure may result in an imbalanced foot clinically.

Allograft reconstruction of Peroneus longus and brevis tendons tears arising from a single muscular belly. Case report and surgical technique

Anatomic variants of the peroneal tendons may cause tendon disorders. Moreover, there is a lack of evidence on how to address chronic tendon pathology when a variant of the peroneal tendons is causing the patients symptoms. We present a patient with an uncommon peroneal muscle presentation: a single muscular belly dividing into both the peroneus longus and brevis tendons. After extensive debridement of tendinopathic tissue, primary repair or tenodesis was not possible; therefore a unique solution for this problem was performed, reconstructing both peroneal tendons using a semitendinosus allograft.

Management of Cartilage Injuries of the Foot and Ankle in Handball

In prospective season-long observation studies of handball, the lower extremity is marginally more frequently affected compared with the upper limb [1]. As with many other sports where physical contact occurs, the incidence of injury during match play of 13.5 injuries per 1000 h far exceeds training 0.8 injuries per 1000 h [2].

Management of Chronic Ankle Instability in the Handball Player

Handball is a fast contact sport, resulting in high loading forces to both the upper and the lower limbs, leading to both acute and chronic injuries. Surveys from international and national multisport events have shown handball to be among those with the highest injury rate [1–3].