Sandeep Patel

First Metatarsophalangeal Joint Arthrodesis and Revision Arthrodesis

Arthrodesis of the first metatarsophalangeal joint is a powerful procedure that can improve the load-bearing capabilities of the forefoot and assist in medial arch stability. It is the mainstay of treatment for patients with severe arthritic deformity of the great toe joint, because it addresses the importance first ray weight-bearing has on the rest of the foot. In select individuals, fusion can also be effective as a primary procedure in the treatment of hallux valgus. Rather than cause detrimental effects to the function of the foot, this article suggests that first metatarsophalangeal arthrodesis can actually improve faulty mechanics secondary to a dysfunctional joint.

The Effect of the Lapidus Arthrodesis on the Medial Longitudinal Arch: A Radiographic Review

We reviewed the medical records and radiographs of 35 patients (3 males, 32 females; mean age 40.8 years) who underwent isolated, modified Lapidus arthrodesis for forefoot pathology in 39 feet. The purpose of the review was to evaluate the structural radiographic changes of the medial longitudinal arch (MLA) following isolated arthrodesis of the first tarsometatarsal joint. Pre- and postoperative standardized measurements of sagittal plane views of the foot were assessed to examine change in the MLA construct. The talo-first metatarsal angle and medial cuneiform height both had statistically significant changes, 2.97 degrees (range, 0-11.5 degrees) and 3.44 mm (range, 0-13 mm) (P < .0001) respectively. Our findings suggest that the Lapidus arthrodesis may influence the medial longitudinal arch.

Modified Lapidus Arthrodesis With Crossed Screw Fixation: Early Weightbearing in 136 Patients

Modified Lapidus arthrodesis is a versatile and powerful procedure for correcting the hallux valgus deformity typically associated with significant metatarsus primus varus or increased first ray mobility. Traditionally, patients have remained non-weightbearing until the arthrodesis has consolidated. More recently, numerous studies have evaluated the outcomes of early postoperative weightbearing using a variety of fixation constructs. The present retrospective cohort study evaluated 136 consecutive patients who had undergone modified Lapidus arthrodesis for hallux valgus deformity with conventional, crossed, solid core, screw fixation, were enrolled in an early weightbearing protocol, and were followed for 12 months. All the patients were partial weightbearing in a protective boot a mean of 12.2 (SD ± 4.36) days after surgery, with full weightbearing at 34.4 (SD ± 11.89) days. Union was achieved in 133 patients (97.8%). Of the 3 (2.2%) patients with nonunion, 2 (1.5%) remained asymptomatic. The mean time to radiographic union was 65 (SD ± 37.24) days. Significant improvement was seen in the first intermetatarsal angle and hallux abductus angle after surgery (p < .0001). Deformity correction was not compromised by early weightbearing and was well maintained over time. These results support early weightbearing with traditional crossed screw fixation for modified Lapidus arthrodesis with outcomes and complication rates comparable to those previously published.

A Biomechanical Comparison of Locking Versus Conventional Plate Fixation for Distal Fibula Fractures in Trimalleolar Ankle Injuries

Previous biomechanical studies have advocated the use of locking plates for isolated distal fibula fractures in osteoporotic bone. Complex rotational ankle injuries involve an increased number of fractures, which can result in instability, potentially requiring the same fixed angle properties afforded by locking plates. However, the mechanical indication for locking plate technology has not been tested in this fracture model. The purpose of the present study was to compare the biomechanical properties of locking and conventional plate fixation for distal fibula fractures in trimalleolar ankle injuries. Fourteen (7 matched pairs) fresh-frozen cadaver leg specimens were used. The bone mineral density of each was obtained using dual x-ray absorptiometry scans. The fracture model simulated an OTA 44-B3.3 fracture. The syndesmosis was not disrupted. Each fracture was fixated in the same fashion, except for the distal fibula plate construct: locking (n = 7) and one-third tubular (n = 7). The specimens underwent axial and torsional cyclic loading, followed by torsional loading to failure. No statistically significant differences were found between the locking and conventional plate constructs during both fatigue and torque to failure testing (p > .05). Our specimen bone mineral density averages did not represent poor bone quality. The clinical implication of the present study is that distal fibular locking plates do not provide a mechanical advantage for trimalleolar ankle injuries in individuals with normal bone density and in the absence of fracture comminution.

Is It Worth Discriminating Against Patients Who Smoke? A Systematic Literature Review on the Effects of Tobacco Use in Foot and Ankle Surgery

ABSTRACT Although numerous studies have linked smoking with lower extremity wound and bone healing complications, a comprehensive study on the effects of smoking in foot and ankle surgery has not yet been reported. The purpose of the present study was to report the results of our systemic literature review, identifying the effects of tobacco use on common foot and ankle procedures. The systematic literature review was performed according to guidelines set by the PRIMSA statement (Preferred Reporting Items for Systematic Review and Meta‐Analyses). Smoking, as a single risk factor, was analyzed and used to compare adverse outcomes in the postoperative setting of foot and ankle surgery. We reviewed 528 abstracts that met our initial identification criteria. After an extensive review process, 46 of the articles (8.71%) met the eligibility requirements to be included in the present study. Distal bunionectomy with osteotomy, first metatarsophalangeal joint arthrodesis, Lapidus bunionectomy, toe amputation, transmetatarsal amputation, Symes amputation, open reduction internal fixation (ORIF) of calcaneal fractures, ankle fracture ORIF, pilon fracture ORIF, subtalar arthrodesis, rearfoot arthrodesis, tibiocalcaneal arthrodesis, ankle arthrodesis, total ankle arthroplasty, and plastic surgery procedures and their respective negative association with smoking was identified and described in our review. Our systematic literature review revealed that procedures involving arthrodesis, fracture ORIF, and plastic surgery were associated with negative outcomes in smokers. Procedures that did not involve osseous unions such as total ankle arthroplasty and amputations did not appear to have negative outcomes associated with smoking.

Early Protected Weightbearing After Ankle Fractures in Patients With Diabetes Mellitus.

Abstract The traditional protocol for treatment after ankle fracture in the diabetic patient involves a period of prolonged non‐weightbearing to reduce the incidence of complications. The goal of the present study was to identify the risk factors and complications associated with early protected weightbearing after closed ankle fractures in patients with diabetes. The data from 73 diabetic patients with operatively and nonoperatively treated ankle fractures were retrospectively reviewed. All patients were allowed to begin protected weightbearing in a cast or removable boot at 2 weeks after the index injury or surgery. The mean follow‐up period was 51 (range of 26 to 480) weeks. Complications occurred in 25% of the operative cases and 8% of the nonoperative cases. In both categories, the complication rate was less than that from existing reports using prolonged non‐weightbearing. Wound dehiscence was the most common complication in the operatively treated patients (18.8%). A statistically significant difference was found in the complications rates for the patients aged >60 years (p = .0403). No statistically significant differences were identified according to hemoglobin A1c, the presence of peripheral neuropathy, smoking status, fracture type, or the presence of end‐stage renal disease. The results of the present study suggest that early protected weightbearing after closed ankle fractures in diabetic patients is fairly safe, with an acceptable complication rate. However, the patients selected for early weightbearing had low comorbidity profiles, which might have accounted, in part, for the low complication rate. &NA; Level of Clinical Evidence: 4