Martin J. O’Malley

Posterior Tibial Tendon Insufficiency Results at Different Stages

The results of surgical treatment of posterior tibial tendon insufficiency (PTTI) may be different at different stages of the disease. No single study has compared the results at different stages. This comparison can be helpful to the patient and physician if the patient asks “What if I wait and the disease progresses, how will my results be different?” A preliminary study comparing results for stage IIa, stage IIb (advanced stage II), and stage III was performed followed by a larger study comparing IIa and IIb with 26 and 22 patients, respectively. American Orthopaedic Foot and Ankle Society (AOFAS) outcome scores as well as radiographs and functional questions were used. Nearly all patients, regardless of stage, felt they were helped by surgical treatment. However, the lowest AOFAS score was in stage III, the most advanced stage investigated in this study. In comparing stage IIa and IIb patients, stage IIb patients had a statistically higher incidence of lateral discomfort. Although statistically significant differences were not found in all comparisons, this study suggests that the results of surgical treatment for PTTI declines with increasing stage or severity of disease.

Arthroscopic Bone Marrow Stimulation and Concentrated Bone Marrow Aspirate for Osteochondral Lesions of the Talus: A Case-Control Study of Functional and Magnetic Resonance Observation of Cartilage Repair Tissue Outcomes.

PURPOSE This study compares retrospective functional and magnetic resonance imaging (MRI) outcomes after arthroscopic bone marrow stimulation (BMS) with and without concentrated bone marrow aspirate (cBMA) as a biological adjunct to the surgical treatment of osteochondral lesions (OCLs) of the talus. METHODS Twenty-two patients who underwent arthroscopic BMS with cBMA (cBMA/BMS group) for an osteochondral lesion (OCL) of the talus and 12 patients who underwent arthroscopic BMS (BMS alone) for an OCL of the talus were retrospectively reviewed. The Foot and Ankle Outcome Score (FAOS) pain subscale and Short Form 12 general health questionnaire physical component summary score (SF-12 PCS) provided patient-reported outcome scores pre- and postoperatively. MRI scans were assessed postoperatively using the magnetic resonance observation of cartilage repair tissue (MOCART) score. All patients had postoperative MRI performed at the 2-year postoperative visit, and quantitative T2 mapping relaxation time values were assessed in a subset of the cBMA/BMS group. RESULTS The mean FAOS and SF-12 PCS scores improved significantly pre- to post-operatively (P < .01) at a mean follow-up of 48.3 months (range, 34 to 82 months) for the cBMA/BMS group and 77.3 months (range, 46 to 100 months) for the BMS-alone group. The MOCART score in the cBMA/BMS group was significantly higher than that in the BMS-alone group (P = .023). Superficial and deep T2 relaxation values in cBMA/BMS patients were higher in repair tissue compared with measurements in adjacent native articular cartilage (P = .030 and P < .001, respectively). CONCLUSIONS BMS is an effective treatment strategy for treatment of OCLs of the talus and results in good medium-term functional outcomes. Arthroscopic BMS with cBMA also results in similar functional outcomes and improved border repair tissue integration, with less evidence of fissuring and fibrillation on MRI.

Achilles tendon rupture in women.

Background: The incidence of Achilles rupture appears to be less in women, although this notion has not been specifically investigated in the literature. Methods: The medical records of 7 foot-and-ankle orthopaedic surgeons at 1 institution were reviewed by Current Procedural Terminology (code 27650) and International Classification of Diseases–9 (code 727.67) to establish all Achilles tendon ruptures seen and/or treated by these surgeons. Sex, age, side, and mechanism of injury were recorded. Whether the patient had an acute Achilles tendon rupture or nonacute Achilles pathology was also noted. Results: A total of 468 patients were identified, of whom 358 had acute ruptures: 302 male and 56 female (5.39:1). Patients with acute ruptures were significantly younger than those with nonacute pathology (43.8 vs 55.1, P < .001). For acute ruptures, the mean age was not significantly different between men and women (43.9 vs 43.2; P = .780). Athletic activity was causative in 243 of 302 men (80.5%) and in 40 of 56 women (71.4%). This difference was not statistically significant (P = .130). Six men (2.0%) and 6 women (10.7%) had comorbidities that were thought to increase their risk of rupture (P = .005). Conclusion: Achilles tendon rupture is more common in men than women. Previous studies using the aforementioned codes to identify patients without chart review may have overestimated the number of women with acute Achilles tendon rupture. Level of Evidence: Level III, retrospective comparative series.

Treatment of Advanced Stages of Hallux Rigidus with Cheilectomy and Phalangeal Osteotomy

BACKGROUND Surgical treatment of hallux rigidus has usually consisted of cheilectomy for mild to moderate disease and arthrodesis for more advanced disease. The reported failure rate for cheilectomy alone in patients with advanced disease is approximately 37.5%. We reported our results with the combination of cheilectomy and extension osteotomy at the proximal phalanx for the treatment of advanced hallux rigidus. METHODS Between 2000 and 2007, eighty-one patients with advanced hallux rigidus (classified as Hattrup and Johnson Grade III) underwent a unilateral cheilectomy and great toe proximal phalangeal extension osteotomy. Outcome assessment was determined by comparison of preoperative and postoperative American Orthopaedic Foot & Ankle Society scores, radiographs, first metatarsophalangeal joint motion, and patient satisfaction. Sixty-four of the eighty-one patients had complete clinical and radiographic examinations at a minimum duration of follow-up of two years. RESULTS The mean duration of follow-up was 4.3 years. The mean dorsiflexion of the first metatarsophalangeal joint improved significantly (p < 0.05), by 27.0°, from 32.7° preoperatively to 59.7° postoperatively. The average American Orthopaedic Foot & Ankle Society scores improved significantly (p < 0.05) from 67.2 points preoperatively to 88.7 points postoperatively. Radiographs of the interphalangeal joint made postoperatively showed no evidence of development of interphalangeal joint arthritis. Of the eighty-one patients, sixty-nine (85.2%) were satisfied with the results of treatment and four (4.9%) subsequently underwent arthrodesis to treat persistent symptoms at the first metatarsophalangeal joint. CONCLUSIONS To our knowledge, this study is the first to support the use of a combination of cheilectomy and extension osteotomy of the great toe proximal phalanx as an alternative to first metatarsophalangeal joint arthrodesis to manage patients with advanced hallux rigidus.

Operative Treatment of Fifth Metatarsal Jones Fractures (Zones II and III) in the NBA.

Background: Proximal fractures of the fifth metatarsal (zone II and III) are common in the elite athlete and can be difficult to treat because of a tendency toward delayed union, nonunion, or refracture. The purpose of this case series was to report our experience in treating 10 NBA players, determine the healing rate, return to play, refracture rate, and role of foot type in these athletes. Methods: The records of 10 professional basketball players were retrospectively reviewed. Seven athletes underwent standard percutaneous internal fixation with bone marrow aspirate concentrate (BMAC) whereas the other 3 had open bone grafting primarily in addition to fixation and BMAC. Radiographic features evaluated included fourth-fifth intermetatarsal, fifth metatarsal lateral deviation, calcaneal pitch, and metatarsus adductus angles. Results: Radiographic healing was observed at an overall average of 7.5 weeks and return to play was 9.8 weeks. Three athletes experienced refractures. There were no significant differences in clinical features or radiographic measurements except that the refracture group had the highest metatatarsus adductus angles. Most athletes were pes planus and 9 of 10 had a bony prominence under the fifth metatarsal styloid. Conclusion: This is the largest published series of operatively treated professional basketball players who exemplify a specific patient population at high risk for fifth metatarsal fracture. These players were large and possessed a unique foot type that seemed to be associated with increased risk of fifth metatarsal fracture and refracture. This foot type had forefoot metatarsus adductus and a fifth metatarsal that was curved with a prominent base. We continue to use standard internal fixation with bone marrow aspirate but advocate additional prophylactic open bone grafting in patients with high fourth-to-fifth intermetatarsal, fifth metatarsal lateral deviation, and metatarsus adductus angles as well as prominent fifth metatarsal styloids in order to improve fracture healing and potentially decrease the risk of refracture. Level of Evidence: Level IV, case series.

Anterior ankle arthrodesis

Ankle arthrodesis is a common procedure that resolves many conditions of the foot and ankle; however, complications following this procedure are often reported and vary depending on the fixation technique. Various techniques have been described in the attempt to achieve ankle arthrodesis and there is much debate as to the efficiency of each one. This study aims to evaluate the efficiency of anterior plating in ankle arthrodesis using customised and Synthes TomoFix plates. We present the outcomes of 28 ankle arthrodeses between 2005 and 2012, specifically examining rate of union, patient-reported outcomes scores, and complications. All 28 patients achieved radiographic union at an average of 36 wk; the majority of patients (92.86%) at or before 16 wk, the exceptions being two patients with Charcot joints who were noted to have bony union at a three year review. Patient-reported outcomes scores significantly increased (P < 0.05). Complications included two delayed unions as previously mentioned, infection, and extended postoperative pain. With multiple points for fixation and coaxial screw entry points, the contoured customised plate offers added compression and provides a rigid fixation for arthrodesis stabilization.

Morbidity and Complications Following Percutaneous Calcaneal Autograft Bone Harvest

Background: Autogenous bone grafting is commonly used as an adjuvant in foot and ankle procedures. The iliac crest and tibia are common sources of autogenous bone graft but require a separate operative site and have been reported to have significant morbidity including pain, fractures, and prolonged hospitalization. Bone grafting from the posterolateral calcaneus offers advantages such as a single operative field, ability to be done under an ankle block, and a theoretical low complication rate. We report our morbidity and complications of percutaneous calcaneal autograft bone harvest in patients undergoing foot operations. Methods: Between 2006 and 2010, 6 foot and ankle surgeons performed a calcaneal bone graft on 393 patients undergoing foot procedures. Outcomes were measured through the use of a 4-question survey evaluating pain, subjective sensitivity at the incision site, numbness at the incision site, and limitation of shoe wear at a minimum of 1 year following the operation. Patient records were also examined for any additional complications that may have been reported. Results: Of the 393 patients eligible for this study, 210 patients responded at an average of 2.8 years (range, 1.2-5.8 years) after the operation (minimum 1 year). Of those, 181 patients (86.2%) reported no problems. Minor complications included 6 patients (2.9%) who experienced only incisional nerve sensitivity, 4 patients (1.9%) with only incisional pain, 4 patients (1.9%) who reported some degree of incisional numbness only, 2 patients (1.0%) who reported only shoe wear limitations, and 10 patients (4.8%) who had a combination of symptoms. Three patients (1.4%) had more significant complications, which consisted of a pathological fracture through the graft site, a calcaneal stress fracture, and 1 patient with permanent numbness along the distribution of the sural nerve. Conclusion: Calcaneal bone graft was an easily accessible source of local autogenous bone graft for foot and ankle procedures. Despite the simplicity of the procedure, minor complications are not infrequent, with 13.8% of patients reporting some residual symptoms along the lateral border of the calcaneus when bone graft was obtained through an oblique incision. Level of Evidence: Level IV, case series.

Functional Outcomes Following First Metatarsophalangeal Arthrodesis

Background: First metatarsophalangeal (MTP) joint arthrodesis is a common procedure for treatment of arthritis of the first MTP joint. The primary aim of this study was to evaluate the functional outcomes of a series of patients of multiple surgeons undergoing first MTP joint arthrodesis, emphasizing the functional gains with respect to daily activity that can be expected after this procedure. Methods: A retrospective review of 53 patients who underwent successful isolated first MTP joint arthrodesis with either a plate and screw or independent screw construct was performed at our institution over a 6-year period. Successful fusion was defined as no lucency at the first MTP joint and bridging of 2 or more cortices on the anteroposterior, lateral, and oblique radiographic views at final follow-up. Demographic information and radiographs were evaluated for all patients. Preoperative and postoperative Foot and Ankle Outcome Score (FAOS) and Short Form Health Status Survey (SF) 36/12 functional outcome scores, as well as responses from an activity- and footwear-specific questionnaire, were evaluated and compared between the 2 fixation methods. Fifty-three patients (56 feet) had radiographs showing successful fusions after being treated for advanced degenerative arthritis of the first MTP joint with arthrodesis. Average time to union was 5.4 months. Results: There was a significant reduction in difficulty in performing daily activities, with all subscales of the FAOS and the SF-12v2 significantly improving postoperatively (P < .05). The majority of patients stated that their foot looked and felt better and were satisfied with the procedure. Five patients experienced painful hardware, which required removal. Conclusion: First MTP joint arthrodesis was successful in improving patient-reported outcomes, particularly the ability to perform daily activities. Most patients had little to no functional limitation and were satisfied with their outcome. The greatest functional improvements were seen in patients’ ability to walk distances and perform low-impact sport activity. Level of Evidence: Level III, retrospective comparative study.

Autograft and allograft unite similarly in lateral column lengthening for adult acquired flatfoot deformity.

BackgroundLateral column lengthening (LCL) is used to address the forefoot abduction associated with the adult acquired flatfoot. This opening wedge osteotomy can be filled with either allograft or autograft bone.Questions/PurposesThe investigators sought to determine union rates and any loss of correction in patients undergoing LCL with autograft versus allograft.MethodsOver a 3-year period, 126 LCLs performed by five surgeons in 120 patients were reviewed. Autograft was used in 51 patients, allograft in 75 patients. Times to clinical and radiographic union were established for these patients. Any loss of correction of forefoot abduction as manifested by talonavicular uncoverage was recorded for those grafts that healed. Failure was defined as nonunion or loss of 50% or greater correction. The size of the implanted graft was assessed as a risk factor for failure.ResultsThere were 20 total failures: seven in patients with autograft and 13 in patients with allograft (p = 0.63). The size of the implanted graft was larger in those patients that did fail (p = 0.04).ConclusionsThe rate of nonunion and loss of correction for LCL was not significantly different between allograft and autograft. The overall rate of nonunion may be higher than has previously been reported.

Rate of Union After Segmental Midshaft Shortening Osteotomy of the Lesser Metatarsals.

Background: Current literature reports excellent rates of union following various lesser metatarsal osteotomy techniques. However, it is our experience that segmental midshaft shortening osteotomies heal very slowly and have a greater potential for nonunion than has previously been reported. The purpose of this study was to assess union rates and report the time required for segmental midshaft shortening osteotomies to achieve radiographic union. Methods: We reviewed the charts and postoperative radiographs of 58 patients (representing 91 osteotomies) who underwent segmental midshaft shortening osteotomies with internal fixation between January 2009 and December 2013. Radiographs were reviewed to determine when union was achieved. Union was defined as the bridging of 2 or more cortices in the anteroposterior, lateral, and oblique radiographic views. Osteotomies were classified as delayed union if they were not healed at 3 months postoperatively and nonunions if they were not healed at 6 months postoperatively. Results: Overall, 27 of 91 osteotomies met our radiographic classification of union and were healed by 3 months (29.7%). Sixty-nine of the 91 osteotomies healed by 6 months (75.8%) and were considered delayed unions. Twenty-two osteotomies were not healed yet and therefore were considered nonunions (24.2%). Of the 22 nonunions, 7 healed in an additional 2 months (8 months) for an overall healing percentage of 83.5%, (76 of 91). By 10 months, 6 more nonunions were healed (overall healing percentage of 90.1%, 82 of 91). Three additional nonunions went on to heal by 12.9 months, yielding a final union rate of 93.4% (85 of 91), while 6 were still considered nonunions (6.6%). Conclusion: We report that a significant percentage of segmental midshaft metatarsal shortening osteotomies experienced delayed unions and nonunions. These findings contrast those previously reported in the literature that metatarsal osteotomies have very low nonunion rates. These results support our hypothesis that these osteotomies require a prolonged amount of time to achieve bony healing and that they have a higher tendency to develop delayed and nonunions than previously reported. Level of Evidence: Level IV, retrospective case series.