Michael S. Hennessy

Management of Posterior Malleolar Fractures: A Systematic Review.

Posterior malleolar fractures are relatively common and usually result from rotational ankle injuries. Although treatment of associated lateral and medial structures is well established, several controversies exist in the management of posterior malleolus fractures. We performed a systematic review of the current published data with regard to the diagnosis, management, and prognosis of posterior malleolus fractures. A total of 33 studies (8 biomechanical and 25 clinical) with >950 patients were reviewed. The outcome of ankle fractures with posterior malleolar involvement was poor; however, the evidence was not enough to prove that the size of the posterior malleolus affects the outcome. Significant heterogeneity was noted in the cutoff size of the posterior malleolar fragment in determining management. The outcome was related to other factors, such as fracture displacement, congruency of the articular surface, and residual tibiotalar subluxation. Indirect evidence showed that large fracture fragments were associated with fracture dislocations and ankle instability and, thus, might require surgical fixation. We have concluded that the evidence to prove that the size of the posterior malleolar affects the outcome of ankle fractures is not enough, and the decision to treat these fractures should be determined by other factors, as stated previously.

Management of the varus arthritic ankle.

Treatment of the arthritic varus ankle presents a significant surgical challenge. The recognition of the causes and associated deformities directs the treatment of the individual patient and optimizes functional outcome. Arthrodesis and total ankle replacement often will need to be augmented by corrective hind- and midfoot procedures and by careful soft tissue balancing. Often multiple procedures are required to achieve the desired result, and patients need to be advised that surgery may need to be staged.

Arthroscopic Evaluation of Impingement and Osteochondral Lesions in Chronic Lateral Ankle Instability

Background: Anterolateral impingement associated with intra-articular synovitis, scarring, and fibrosis is a less recognized feature in patients with chronic lateral ankle instability. The aim of our study was to ascertain the incidence of intra-articular synovitis, osteochondral lesions (OCLs), impingement lesions (both intra- and extra-articular), and other associated pathologies in patients undergoing modified Broström-Gould ankle ligament reconstruction. Methods: We performed a retrospective review of all patients who underwent arthroscopically assisted modified Broström-Gould ankle ligament reconstruction for symptomatic recurrent ankle instability. Patients who had previous ankle surgery or inflammatory arthropathy were excluded. Ankle arthroscopy was performed prior to reconstruction in all patients. Data were obtained from clinical and radiological records including magnetic resonance imaging scans. Arthroscopic findings were recorded in detail intraoperatively. A total of 100 patients (53 females and 47 males) with an average age of 37 years (range, 15-65 years) were reviewed over a 10-year period. Results: Sixty-three patients (63%) had intra-articular synovitis mostly in the anterior and/or anterolateral compartment, which required arthroscopic debridement. Seventeen patients (17%) were found to have OCLs, and 12 (12%) patients had anterior bony impingement lesions. Conclusion: This study found a high incidence of anterior/anterolateral synovitis in patients with chronic lateral ankle instability. However, there was a relatively low incidence of anterior bony impingement lesions or OCLs in our series. Level of Evidence: Level IV, retrospective case series.

Traumatic ‘Mallet Toe’ of the Hallux: A Case Report

We describe a case of a traumatic avulsion fracture of the distal phalanx of the hallux. In the upper limb this fracture leads to a “mallet” deformity. Such an injury in the great toe has not been reported previously in the English orthopaedic literature to our knowledge. The injury was treated in a dorsal extension splint for eight weeks. At six months follow-up, a satisfactory clinical outcome was achieved.

Achilles Tendon Rupture Associated with Combination Therapy of Levofloxacin and Steroid in Four Patients and a Review of the Literature

Levofloxacin often is used for the management of community-acquired pneumonia because of its broad-spectrum coverage against common bacterial pathogens, high oral bioavailability, superior tissue penetration, and good tolerability. Tendinitis has been reported as an adverse effect of many fluoroquinolones, but Achilles tendon rupture is a relatively uncommon complication.13 Isolated cases of levofloxacin-induced rupture of the Achilles tendon have been reported.6,8 We report a series of three bilateral ruptures and one unilateral rupture in patients on levofloxacin and steroid therapy.

First metatarsophalangeal arthrodesis for hallux valgus.

Arthrodesis of the first metatarsophalangeal joint is a reliable operation in the treatment of selected cases of hallux valgus. It corrects deformity of hallux valgus and metatarsus primus varus, leading to good functional results with a low complication rate. It is a technique well suited to patients with hallux valgus associated with degenerative changes or severe deformity, and those for whom primary hallux valgus surgery has failed.

Treatment of mucous cysts of the toes

The outcome of surgically treated mucous cysts of the foot is poorly documented in the orthopaedic literature. This study reports on the treatment of mucous cysts of the toes by simple excision and joint debridement. This is in contrast to treatment of similar lesions in the fingers which is often treated by excision of the cyst, joint debridement, and rotational flap. Following this procedure on 15 patients (15 cysts), at a minimum of 2 years postoperatively, only one cyst had recurred at 9 months. All patients were satisfied by the cosmetic appearance of their toe. The authors reviewed the available literature on this condition and suggest that this method of treatment provides good functional and cosmetic results with a minimal rate of recurrence.

Creative cutting to contour and correct Hallux bone graft for three planes of correction

Revision surgery for failed hallux rigidus or valgus is fraught because of bone loss at the first metatarsophalangeal (MTP) joint. This may be related to infection or rheumatoid arthritis-related destruction, however in most cases this is iatrogenic, as a direct result of previous hallux valgus or hallux rigidus surgery. A first MTP joint arthrodesis is often the method of choice to salvage this situation and improve a patient’s symptoms. If there is minimal bone loss a standard first MTP joint fusion can be undertaken, as slight shortening creates only minimal cosmetic concerns and functional loss. Significant bone loss and shortening however, will lead to a cosmetic deformity and also defunction the first ray. Interpositional bone grafts are used to fill the defect and maintain length. The use of single conical reaming of structural allografts has been shown to permit more degrees of freedom for toe positioning, it is reproducible, with high rates of fusion [1–3]. Interpositional tricortical iliac crest grafts have also been shown to effective in subtalar arthrodesis for the management of late pain and deformity after calcaneal fractures [4]. We outline a novel and simple method of double conical reaming of bone autograft to allow for greater flexibility in positioning of the toe which provides an increased surface area, leading to better apposition compared with previously described methods.

Improving the Consent Process in Foot and Ankle Surgery With the Use of Personalized Patient Literature

ABSTRACT A patient‐specific letter was introduced to the consent process to observe the effect, if any, on information recall and satisfaction for patients undergoing elective foot and ankle surgery. The patients attending the clinic were written a personalized letter—this was a simple personalized letter that outlined their treatment options, the proposed management plan, likely treatment course, and the benefits, risks, and likely period required for recovery. The personalized letter system was compared with the 2 existing methods of consent process: signing for consent at their outpatient encounter at which they were scheduled for surgery and a separate consent clinic without the personalized letter. A total of 111 patients (87 females, 24 males) undergoing elective foot and ankle surgery were assessed on the day of surgery for recall of the procedure, risks, postoperative course, and satisfaction with the consent process. Patients receiving a personalized letter recalled more than those who had attended a routine preoperative consent clinic visit and significantly more than those who had provided consent at their last clinic visit. Patient satisfaction with the consent process was also greater in the personalized group. Our results suggest that the consent process is improved using routine preoperative consent clinics and, most notably, with patient‐specific information to improve patient recall and satisfaction. Level of Clinical Evidence: 2