Richard G. Alvarez

Tibiocalcaneal Arthrodesis for the Management of Severe Ankle and Hindfoot Deformities

Purpose: The purpose of this investigation was to evaluate the outcome of tibiocalcaneal arthrodesis using an adolescent condylar blade plate for severe ankle and hindfoot deformities. Materials and Methods: We retrospectively reviewed the records of patients managed at our institutions between 1989 and 1996 whose tibiocalcaneal arthrodeses were performed with adolescent condylar blade plates and allograft bone. In these 30 patients (14 men, 16 women; average age, 53 years), the etiologies of the nonbraceable deformity included: diabetic neuroarthropathy with talar fragmentation and resorption (26), inflammatory arthritis (3), and posttraumatic avascular necrosis of the talus with collapse (1). Due to the severity of the deformity in 28 of these patients, the alternative treatment would have been amputation. Thirteen patients had undergone previous surgeries, eight had documented osteomyelitis, and 13 had ulcers ranging from 2 to 27 mm. At surgery, the remnants of the talus were removed. Morcellized bone graft mixed with tobramycin/vancomycin powder was inserted into the arthrodesis site and then fixed with a rigid plate. Intravenous antibiotics, followed by oral antibiotics, were given until wound healing and suture removal. Follow-up averaged 48 months (19 to 112 months). Results: Tibiocalcaneal fusion was achieved in 28/30 patients at an average of 16 weeks (12 to 18 weeks). Complications occurred in seven patients: two developed stress fractures of the tibia at the proximal end of the blade plate, three had superficial cellulitis that resolved with antibiotic therapy, and two had nonunions. Conclusion: Tibiocalcaneal arthrodesis using an adolescent condylar blade plate and allograft bone can be a successful procedure in the patient with severe neuropathic ankle deformity and can achieve a stable plantigrade foot for limited community ambulation with relatively few complications.

Tibiocalcaneal Arthrodesis for Nonbraceable Neuropathic Ankle Deformity

Seven patients with nonbraceable, neuropathic ankle joints have been successfully treated by tibiocalcaneal arthrodesis utilizing an adolescent condylar blade plate, large cannulated AO screws, and a special cancellous allograft mixture. All patients had fragmentation and partial resorption of the talus. This procedure was considered as an alternative to below-knee amputation. Goals were limb salvage and limited community ambulation.

The simple bunion: Anatomy at the metatarsophalangeal joint of the great toe

The pathomechanics for the development of the hallux valgus deformity takes place at the first metatarsophalangeal joint-the sesamoid complex. The sesamoid complex consists of seven muscles, eight ligaments, and two sesamoid bones. When the first metatarsal escapes the complex and drifts medially, the sesamoids remain twisted in situ, several of the ligaments “fail,” and others contract. The authors propose reduction of the metatarsus primus varus by first metatarsal osteotomy and appropriate ligament releases and plications to restore alignment. A detailed understanding of the pathomechanics is essential for proper interpretation of the problems and anticipated lasting surgeries.

Lateral roentgenographic projections of the acromioclavicular joint

Although the acromioclavicular joint is frequently in jured in both contact and noncontact sports, the treat ment is nonspecific, as demonstrated by the numerous methods of treatment currently employed. Despite treatment, some shoulders still develop chronic symp toms and disability during overhead lifting, throwing, and swinging. Perhaps these difficulties develop as a result of an incomplete evaluation of the joint and because the exact nature of the injury is not appreci ated. Therefore, the shoulder develops chronic prob lems. We have routinely utilized a lateral roentgenogram of the acromion to evaluate the acromioclavicular joint. This has significantly aided us in the diagnosis and treatment of acromioclavicular joint injuries, es pecially when there was posterior dislocation of the distal clavicle. This presentation reviews standard roentgenogra phy of the acromioclavicular joint and illustrates the method of obtaining the lateral projection as described by O. M. Alexander. We will also show how this method has helped us clinically in detecting posterior dislocations of the distal end of the clavicle.

Extracorporeal Shock Wave Treatment of Non- or Delayed Union of Proximal Metatarsal Fractures

Background: Nonunion or delayed union of fractures in the proximal aspect of metatarsals 1 to 4 and Zone 2 of the fifth metatarsal were treated by high energy extracorporeal shock wave treatment (ESWT) to study the safety and efficacy of this method of treatment in a FDA study of the Ossatron device. Materials and Methods: In a prospective single-arm, multi-center study, 34 fractures were treated in 32 patients (two subjects had two independent fractures) with ESWT. All fractures were at least 10 (range, 10 to 833) weeks after injury, with a median of 23 weeks. ESWT application was conducted using a protocol totaling 2,000 shocks for a total energy application of approximately 0.22 to 0.51 mJ/mm2 per treatment. The mean ESWT application time for each of the treatments was 24.6 ± 16.6 minutes, and anesthesia time averaged 27.1 ± 10.4 minutes. All subjects were followed for 1 year after treatment at intervals of 12 weeks, 6, 9, and 12 months. Results: The overall success rate at the 12-week visit was 71% with low complications, significant pain improvement as well as improvement on the SF-36. The success/fail criteria was evaluated again at the 6- and 12-month followup, showing treatment success rates of 89% (23/26) and 90% (18/20), respectively. The most common adverse event was swelling in the foot, reported by five subjects (15.6%). Conclusion: High-energy ESWT appears to be effective and safe in patients for treatment of nonunion or a delayed healing of a proximal metatarsal, and in fifth metatarsal fractures in Zone 2. Level of Evidence: IV, Retrospective Case Series

Symptom Duration of Plantar Fasciitis and the Effectiveness of Orthotripsy

Background: The use of surgically noninvasive application of Orthotripsy® (extracorporeal shock waves) for various musculoskeletal disorders is being increasingly utilized. Because most patients have had prolonged symptoms refractory to nonoperative treatments, this study evaluated the effectiveness of electrohydraulic Orthotripsy for chronic proximal plantarfasciitis compared to the duration of symptoms prior to treatment. Methods: Following evaluation for study inclusion (unresponsive symptoms for more than 6 months), qualified patients received Orthotripsy or placebo. The study patients were randomized per described protocol. Additional groups of nonrandomized patients also were studied. Results: In both the randomized and nonrandomized patient groups, those who received Orthotripsy were slightly more likely to have a positive result (complete symptom relief or satisfactory improvement) if symptoms had been present and unresponsive to other nonoperative therapeutic attempts for less than 2 years. The same trend was evident in patients undergoing a second Orthotripsy application. In the placebo group, there was no correlation between symptom duration and outcome. However, when placebo patients crossed over to the treatment arm of the study, the same response was evident: patients with symptoms for less than 2 years were slighty more likely to have a positive therapeutic response. Interestingly, the two patients with the longest duration of symptoms (15 and 18 years) both had complete symptom relief. Conclusions: The longevity of symptoms of chronic proximal plantar fasciopathy had a minimal impact on the likelihood of a positive response to Orthotripsy.

Plantar fasciopathy and orthotripsy: the effect of prior cortisone injection.

Background: Corticoid steroid injection into the heel is a popular treatment method for painful heel syndromes. However, the positive results usually are short term. Extracorporeal shock wave treatment (ESW) has been shown to have a more permanent effect. We evaluated 555 patients who received ESW using the device Ossa Tron Orthotripsy® (Health Tronics, Surgical Services, Marietta, GA) relative to antecedent cortisone heel injection. Methods: Before ESW, 312 patients (56%) received one or more cortisone injections into the heel, and 243 patients (44%) had never received a cortisone injection. Results: Two hundred and thirty-four patients (75%) who had antecedent injection or injections had positive outcomes after ESW. One hundred sixty-eight patients (69%) without prior heel injection had positive responses after ESW. Conclusion: The prior injection of cortisone did not affect the likelihood of a positive response to ESW. Similarly, the absence of prior injection of cortisone did not affect the outcome.

Technical tip: arthroscopic assistance in minimally invasive curettage and bone grafting of a calcaneal unicameral bone cyst.

Unicameral bone cysts (UBC) are benign fluid-filled cystic lesions most commonly found in the proximal humerus and proximal femur in children. Several reports have described lesions in the calcaneus; however, these lesions remain relatively uncommon.1,3 While these are benign lesions, they do predispose the patient to the risk of pathologic fracture, which is a significant morbidity especially in weightbearing bones such as the calcaneus. The treatment of UBC has evolved over time from open curettage and bone grafting to less invasive percutaneous techniques.1,5 The percutaneous approach decreases softtissue complications but sacrifices direct exposure. Inadequate exposure potentially compromises patient outcomes because the risk of recurrence is increased with incomplete cyst resection.2 This cannot be underestimated as the documented risk of UBC recurrence is as high as 30%.4 In addition, poor exposure of the lesion may lead to suboptimal bone grafting. For this reason cystograms often are used to assess the size of the lesion and further confirm adequate filling of the lesion with bone graft. However, this still only provides indirect exposure, which has limitations. Specifically, indirect techniques do not allow adequate protection of internal support structures. Preoperative planning and the use of CT are important in the guidance of the procedure but cannot replace direct exposure. We used an arthroscope with a minimally invasive approach to allow direct observation of the curettage and, importantly, to allow us to maintain the internal structural support of the septated cyst. The calcaneal lesion in our patient had multiple bony pillars formed within the cyst cavity that were visible on preoperative CT (Figure 1). Of principle concern in this active patient was maintaining these

Nonoperative management of retrocalcaneal pain with AFO and stretching regimen.

Background: Retrocalcaneal heel pain is caused by a spectrum of etiologies all resulting in the same symptom of pain at the tendon-Achilles insertion. Several studies have reported the outcomes of operative treatment, but none have reported the outcomes or success rates of nonoperative treatment. We describe a detailed treatment algorithm and report the clinical outcomes. Methods: One hundred thirty-five patients were prescribed a treatment regimen consisting of an AFO and stretching program and were enrolled in our prospective study. One hundred three patients completed pre- and post-treatment Foot Function Indices and were included in the analysis. The effect on FFI from clinical and radiographic factors was examined. Results: Of the study population, 76% had a BMI greater than 25, 80% were older than 50 years, and 75% had an exostosis on radiographs. The mean pre-treatment FFI was 48.4 and the mean post-treatment FFI was 18.6 indicating a statistically significant improvement in function of 29.8. Neither BMI nor age had a significant effect on the magnitude of improvement; though, smokers had significantly less improvement. FFI improvement in patients with an exostosis were less than those without an exostosis. Patients with an exostosis less than 1 cm had less improvement than those with an exostosis of 1 cm or more. Patients with Types I and III exostoses had significantly less improvement in FFI compared to Types II and IV. Twelve of the 103 (11.6%) were not pleased with the results of nonoperative treatment and elected to have a procedure performed. Conclusion: Our study is the first to report the outcome of non operatively treated retrocalcaneal heel pain and to classify retrocalcaneal exostoses. Using our treatment algorithm, we had an 88% success rate in alleviating symptoms and avoiding surgery. Our data suggests that the use of an AFO and stretching regimen may benefit patients suffering from retrocalcaneal heel pain. Level of Evidence: IV, Case Series

Arteriovenous Fistula and Pseudoaneurysm of the Posterior Tibial Artery After Calcaneal Slide Osteotomy: A Case Report

Level of Evidence: V, Expert Opinion