Philip Basile

Meta-analysis of first metatarsophalangeal joint implant arthroplasty.

UNLABELLED Management of late-stage degenerative joint disease of the first metatarsophalangeal joint (MPJ) is a complex topic that is frequently the source of debate among foot and ankle surgeons. Several surgical interventions have been described to treat this condition. One of the most contested of these treatments is implant arthroplasty of the first MPJ. The primary aim of this meta-analysis was to evaluate the clinical benefit of first MPJ implant arthroplasty in regard to patient satisfaction. Reviewers formally trained in meta-analysis abstraction techniques searched databases and indices using medical subject heading terms and other methods to identify all relevant studies published since 1990. Initially, 3874 citations were identified and evaluated for relevance. Abstract screening produced 112 articles to be read in entirety, of which 47 articles studying 3049 procedures with a mean 61.48 (SD 45.03) month follow-up met all prospective inclusion criteria necessary for analysis. Overall crude patient satisfaction following first MPJ implant arthroplasty was 85.7% (95% confidence interval: 82.5%-88.3%). When adjusting for lower quality studies (retrospective, less than 5 years of follow-up, higher percent of patients lost to follow-up), the overall patient satisfaction increased to 94.5% (89.6%-97.2%) in the highest-quality studies. This adjustment also significantly decreased heterogeneity across studies (crude Q = 184.6, high-quality studies Q = 2.053). Additional a priori sources of heterogeneity were evaluated by subgroup analysis and meta-regression. In regards to patient satisfaction, this comprehensive analysis provides supportive evidence to the clinical benefit of first MPJ implant arthroplasties. LEVEL OF CLINICAL EVIDENCE 1.

Panmetatarsal head resection. A viable alternative to the transmetatarsal amputation.

While the transmetatarsal amputation has resulted in the salvage of numerous diabetic limbs, it remains an ablative procedure with both short- and long-term complications. The authors reviewed their experience with the panmetatarsal head resection as an alternative to the transmetatarsal amputation. A retrospective review was performed of all patients having undergone this procedure between May 1986 and November 1991. Thirty-seven procedures were performed; of these, 34 were evaluated. The average follow-up period was 20.9 months. Thirty-two feet showed primary healing while one showed delayed healing. One patient had local recurrence of the original ulceration. Primary healing was 94% while overall success was 97%. No patient required amputation of any kind. The authors conclude that the panmetatarsal head resection is a viable alternative to the transmetatarsal amputation in properly selected patients because it avoids many of the structural and biomechanical pitfalls of the transmetatarsal amputation.

Identifying Risk Factors in Subtalar Arthroereisis Explantation: A Propensity-matched Analysis

A case-control study was undertaken to identify differences in patients with flexible flatfoot deformity who required explantation of subtalar arthroereisis compared with those who did not. All patients who required removal of a self-locking wedge-type subtalar arthroereisis were identified between 2002 and 2008. Propensity scores matched 22 explanted subtalar arthroereises to 44 controls (nonexplanted arthroereises), resulting in a total of 66 implants that met all inclusion and exclusion criteria. Multivariate logistic regression found that patients who required explantation had a greater odds of radiographic undercorrection, determined from radiographic anteroposterior talar-first metatarsal angles postoperatively, P = .0012, odds ratio (OR) = 1.175 (95% confidence interval [CI] 1.066 to 1.295), or residual transverse plane-dominant deformities, as determined from radiographic calcaneocuboid abduction angles postoperatively, P = .05, OR = 1.096 (95% CI 1.06 to 1.203). Patients with smaller postoperative anteroposterior talocalcaneal angles had a 16.7% reduction in odds for arthroereisis explantation (P = .0019) (95% CI 6.5% to 25.8%). Age, gender, implant size, shape, duration, implant position, surgeon experience, and concomitant procedures were not statistically different between the 2 groups. This study helps identify key factors that may result in subtalar arthroereisis explantation.

Salvaging the ischemic transmetatarsal amputation through distal arterial reconstruction.

From 1982 to 1991, 17 patients underwent a lower extremity arterial bypass to salvage an ischemic transmetatarsal amputation at the New England Deaconess Hospital. Eleven patients were male, and 16 had diabetes for an average of 29 years. The mean age was 71 years. Twelve patients presented with an ischemic ulcer, one had rest pain, and four underwent bypass for failure to heal a transmetatarsal amputation. Twelve patients presented with findings of secondary infection. All 17 patients underwent successful lower extremity bypass procedures to a variety of outflow vessels. Thirteen bypasses were to infrapopliteal arteries, including four to the dorsalis pedis artery. There were no perioperative deaths and all patients were discharged with patent grafts and healing limbs. Actuarial graft patency of the 14 vein grafts was 90% at 2 years. Actuarial limb salvage for the entire group was 93% at 2 years. Thirteen of the 14 patients who maintained patent grafts and healed their transmetatarsal amputations were ambulatory at their last known follow-up examination. Ischemic complications of previously created transmetatarsal amputations are uncommon. However, limb salvage attempts by lower extremity arterial bypass have a high likelihood of success. Major amputation in these patients should not be done without having first undergone a comprehensive vascular evaluation.

Local Care of the Diabetic Foot

Diabetic foot ulcers continue to pose a serious threat to patients with diabetes. The presence of an ulcer significantly increases the risk of amputation. Although treatment of an ulcer depends on the combination of medical and surgical management, many ulcers will heal with conservative care. Local care of the diabetic foot requires that the practitioner have the ability not only to treat ulcerations but also to recognize these problems early on so as to prevent their worsening. This knowledge is paramount for healing diabetic ulcers and preventing infection and subsequent amputation. The goal of healing the diabetic foot in the outpatient setting focuses on maintaining an intact skin envelope. If this fails, infection may develop and amputation may ensue. It is the goal of the practitioner to recognize the at-risk diabetic foot as well as address those problems that may give rise to infection and amputation (1,2).

Medial Column Rodding Facilitated by Transitional Osteochondral Graft

This is a case report using a new technique designed to allow passage of a screw through a joint while simultaneously preserving the joint cartilage. A 58-year-old woman with diabetes with midfoot Charcot neuro-arthropathy underwent reconstruction, which included a medial column rodding. A headless 8.0-mm screw was inserted into the first metatarsal head coursing along the entire medial column after temporary removal of a portion of the osteochondral surface. This allowed the screw to be positioned perpendicular to the medial column joints. Serial radiographs were collected to evaluate alignment, stability, and osteochondral graft incorporation. The patient showed preservation of joint motion and function with complete osteochondral graft incorporation without evidence of joint degeneration or pain after 45 months of follow-up. This is the first study to present the use of a local osteochondral graft to allow passage of a large diameter screw in the foot. Although graft incorporation was complete, the situation regarding joint preservation remains unclear, but midterm follow-up shows promise. Levels of Evidence: Therapeutic, Level IV, retrospective case study

Long-Term Outcomes of Corrective Osteotomies Using Porous Titanium Wedges for Flexible Flatfoot Deformity Correction

Abstract Common corrective osteotomies used in flexible flatfoot deformity reconstruction include Cotton and Evans osteotomies, which require structural graft to maintain correction. Auto‐, allo‐, and xenografts are associated with a number of limitations, including disease transmission, rejection, donor site morbidity, technical challenges related to graft fashioning, and graft resorption. Porous titanium is a synthetic substance designed to address these flaws; however, few studies have been reported on the efficacy, safety, and long‐term outcomes. A multicenter retrospective cohort of 63 consecutive preconfigured porous titanium wedges (PTWs) used in flexible flatfoot reconstructions from June 1, 2009 to June 30, 2015 was evaluated. The primary outcome measure was the pre‐ to postdeformity correction efficacy. The secondary outcomes included maintenance of correction at a minimum follow‐up point of 12 months, complications, graft incorporation, and graft safety profile. Multivariate linear regression found a statistically significant improvement in all radiographic parameters from preoperatively to the final weightbearing radiographs (calcaneocuboid 18.850 ± 4.020 SE, p < .0001; Kites, 7.810 ± 3.660 SE, p = .04; Mearys 13.910 ± 3.100 SE, p = .0001; calcaneal inclination, 5.550 ± 2.140 SE, p = .015). When restricted to patients with >4 years of follow‐up data, maintenance of correction appeared robust in all 4 measurements, demonstrating a lack of bone or graft resorption. No patients were lost to follow‐up, no major complications or implant explantation or migration occurred, and all implants were incorporated. Minor complications included hardware pain from plates over grafts (8%), 1 case of scar neuritis, and a 5% table incidence of transfer pain associated with the PTWs. These results support the use of PTWs for safety and degree and maintenance of correction in flatfoot reconstruction. &NA; Level of Clinical Evidence: 4

Radiographic Union Scoring Scale for Determining Consolidation Rates in the Calcaneus

ABSTRACT The reliable evaluation of osseous consolidation after hindfoot osteotomy can be difficult. Concomitant hindfoot osteotomies often dictate the advancement of weightbearing, and radiographs are the mainstay imaging tool owing to cost, efficiency, and radiation exposure. Understanding the radiographic parameters that can be used to reliably determine osseous healing is paramount. However, currently, no reliable or validated method is available to determine osseous healing of hindfoot osteotomies in irregular bones of the foot. The purpose of the present study was to develop a radiographic healing scoring system that would enhance the diagnostic healing assessment after elective calcaneal osteotomy. We adapted existing orthopedic scales validated for healing in the leg for application in the irregular bones of the foot. A total of 168 cases were evaluated by 6 blinded assessors to test the interrater reliability of subjective healing assessment compared with the proposed scoring system. The radiographs were classified by postoperative period: ≤4 weeks, 5 to 12 weeks, and >12 weeks. The proposed scale had high interrater reliability but was burdensome. Using a priori item reduction protocols, a limited 6‐item scale further improved internal consistency and reduced the burden. The result was excellent interrater reliability (&agr; = 0.98, standard deviation 0.02, 95% confidence interval 0.91 to 0.96) among all assessors when using the scoring scale compared with unacceptable reliability (&agr; = 0.438) for subjective osteotomy healing. The reliability of our system appeared superior to that of subjective assessment of osseous healing alone, even in the absence of clinical correlates after osteotomy of the calcaneus. Level of Clinical Evidence: 2

Development and Validation of the Foot Union Scoring Evaluation Tool for Arthrodesis of Foot Structures

ABSTRACT Reliable evaluation of osseous consolidation after pedal arthrodesis can be difficult, and the presence or absence of radiographic healing often dictates care. Plain radiographs remain the mainstay imaging tool owing to their cost, efficiency, and low radiation exposure. Applying radiographic parameters that can reliably determine osseous healing is essential. However, currently, no reliable or validated measures are available to determine osseous union of any joint in the foot or ankle. The purpose of the present study was to develop a radiographic healing scoring system that would enhance the diagnostic healing assessment after joint arthrodesis of the foot or ankle. We adapted several existing scales previously validated for fracture healing in the leg, because no study has attempted to apply this to a joint fusion model. A total of 150 cases were evaluated by 6 blinded assessors to test the interrater reliability of the subjective healing assessment compared with the proposed scoring system. The radiographs were classified by the postoperative period: ≤4 weeks, 5 to 12 weeks, and >12 weeks. The initial proposed scale was found to have high interrater reliability but was burdensome. Using a priori item reduction protocols, a limited 5‐item scale further improved the internal consistency and reduced the burden. The result was excellent interrater reliability (&agr; = 0.978, standard deviation 0.02, 95% confidence interval 0.96 to 0.99) among all assessors compared with the reduced reliability (&agr; = 0.752) for subjective arthrodesis healing. Intrarater reliability was also found to be superior using a test–retest method. The reliability of this system appeared superior to the subjective assessment of arthrodesis healing, even in the absence of clinical correlates, after foot arthrodesis. Level of Clinical Evidence: 3