Shannon M. Rush

Mesenchymal Stem Cell Allograft in Revision Foot and Ankle Surgery: A Clinical and Radiographic Analysis

UNLABELLED A review was conducted of 23 patients who underwent implantation of mesenchymal stem cell allograft for revision foot or ankle surgery. Composed of viable mesenchymal stem cells derived from cadaveric donor tissue, the graft had osteogenic, osteoinductive, and osteoconductive properties, and was capable of direct new bone formation at the site of implantation. In all of the cases, radiographic new bone formation was observed at the area of implantation and a 91.3% union rate was observed, and no evidence of graft rejection or complications associated with implantation were recorded. Wilcoxon rank sum tests were used to determine whether gender, diabetes, chronic renal insufficiency, neuropathy, number of previous surgeries, and smoking were associated with time to healing. Spearmans rank correlation coefficient was calculated in an effort to identify the influence of continuous numeric variables on the time to bone healing. Based on the outcomes observed in this retrospective study, it appears that mesenchymal stem cell allograft is a beneficial biological adjunct to bone healing, and serves as a suitable bone autograft substitute in revision foot and ankle surgery. LEVEL OF CLINICAL EVIDENCE 4.

Trinity Evolution Mesenchymal Stem Cell Allografting in Foot and Ankle Surgery

Biologic augmentation of orthopaedic procedures is a time-tested useful adjunct. The ability to predictably heal all fractures and arthrodesis procedures is still elusive because of multiple factors. The next frontier in musculoskeletal medicine and surgery will involve increasing biologic manipulation of the healing environment. Mesenchymal stem cell allograft is viable living biologic material that is capable of new bone formation and osteointegration at the implantation site.

Salto Talaris Fixed-Bearing Total Ankle Replacement System

The Salto Talaris total ankle replacement is an anatomically designed fixed bearing prosthesis available in the United States based on the successful design of the mobile-bearing Salto prosthesis available outside the United States. The original mobile-bearing design was modified and the mobile-bearing was transferred to the precision instrumentation at the trial phase evaluation. Instrumentation and technique allow the surgeon to determine the functional joint axis before final implantation. The Salto Talaris total ankle replacement design blends minimal bone resection and optimizes surface area, cortical contact, and ultra-high molecular weight polyethylene conformity. The authors present an overview of the Salto Talaris total ankle replacement surgical technique and pearls for successful application.

Minimally Invasive Approach to Achilles Tendon Pathology

Many surgical procedures have been described for Achilles tendon pathology; however, no overwhelming consensus has been reached for surgical treatment. Open repair using a central or paramedian incision allows excellent visualization for end-to-end anastomosis in the case of a complete rupture and detachment and reattachment for insertional pathologies. Postoperative wound dehiscence and infection in the Achilles tendon have considerable deleterious effects on overall functional recovery and outcome and sometimes require plastic surgery techniques to achieve coverage. With the aim of avoiding such complications, foot and ankle surgeons have studied less invasive techniques for repair. We describe a percutaneous approach to Achilles tendinopathy using a modification of the Bunnell suture weave technique combined with the use of interference screws. No direct end-to-end repair of the tendon is performed, rather, the proximal stump is brought in direct proximity of the distal stump, preventing overlengthening and proximal stump retraction. This technique also reduces the suture creep often seen with end-to-end tendon repair by providing a direct, rigid suture to bone interface. We have used the new technique to minimize dissection and exposure while restoring function and accelerating recovery postoperatively.

Metastatic Calcaneal Lesion Associated with Uterine Carcinosarcoma

Metastatic lesions of uterine carcinosarcoma most commonly occur in the abdomen and lungs and less frequently in highly vascularized bone. We report a rare case of an 86-year-old female with uterine carcinosarcoma with metastasis to the left calcaneus. The patient had a history of uterine carcinosarcoma with hysterectomy and bilateral salpingo-oophorectomy, along with bilateral pelvic and aortic lymphadenectomy, with no adjuvant therapy. The initial pedal complaint was that of left foot pain. The initial radiographic findings were negative; however, magnetic resonance imaging scans revealed a substantial area of marrow edema in the calcaneus. An excisional biopsy was performed, and histopathologic analysis revealed adenocarcinoma with features consistent with the patients previous uterine tumor specimen. The patient was given one treatment of chemotherapy and was discharged to a hospice, where she died of her disease 2 weeks later.

Understanding the postoperative course and rehabilitation protocol for total ankle arthroplasty.

Total ankle arthroplasty has been a topic that has been gaining in popularity as current-generation prostheses allow for surgeons to reproduce anatomic alignment and ultimately improve outcomes. As in all types of total joint replacement, the postoperative course and treatment regime can be as important, if not more important, than the surgery itself. This often-neglected topic is discussed in this issue’s roundtable discussion by a group of surgeons whom I consider to be authorities in both ankle arthroplasty as well as its postoperative course. We have also been fortunate to get the thoughts from a physical therapist who is treating total ankle patients in his clinic on a weekly basis. As surgeons we must remember that what we do outside of the operating room can have a tremendous impact on the outcomes of our patients. I trust you will enjoy this section as much as I have, learning about the different approaches from world-class surgeons in North America. Let us start with the immediate postoperative care of ankle replacements. How are each of you managing your incisions? What type of closure? How are you dressing your total ankles postoperatively? And are you using drains or negative pressure?

Modified Blair tibiotalar arthrodesis for post-traumatic avascular necrosis of the talus: a case report.

Surgical treatment of post-traumatic avascular necrosis of the talus coupled with collapse often results in limited treatment options. Of those options, the Blair tibiotalar arthrodesis has been beneficial in preserving limb length and subtalar motion. The complications associated with Blair tibiotalar arthrodesis have led to modifications to improve stability and functional outcomes with rigid internal fixation. We present the case of a 29-year-old female with a history of an open fracture dislocation of the talus 10 years previously, with subsequent development of avascular necrosis of the talus. The purpose of the present case report was to describe the surgical approach and use of an anterior compression plate to augment the modified Blair tibiotalar arthrodesis.

Titanium Scaffolding: An Innovative Modality for Salvage of Failed First Ray Procedures

Shortening of the first ray is a potential complication associated with first metatarsal procedures. Correction of this deformity conventionally has required the use of a tricortical bone graft to lengthen the bone. Graft complications, including donor site morbidity, poor graft stability, and graft resorption, have revealed a need for an alternative procedure. The present report shows that titanium cage scaffolding has lower extremity applications beyond its previous uses in the ankle and spine. Two patients underwent surgical correction for failed first ray procedures using a titanium cage apparatus with a calcaneal autograft and other biologic agents. The scaffolds were appropriately sized to fill the defect. Patients remained non-weightbearing until radiographic evidence of healing appeared. Success was determined by diminished pain, a return to activity, ambulation, and patient satisfaction. Patients exhibited faster-than-anticipated healing, including a return to protected weightbearing activities and increased stability within 6 weeks. Titanium cage implants provide long-term stability and resistance to stress and strain in the forefoot. The implant we have described, newly applied to the first ray, is analogous to a system used in salvage of failed ankle replacements. In addition to reducing reliance on the iliac crest bone graft, the titanium cage apparatus is advantageous because it is customized to fill a defect using computed tomography scanning, thereby reducing graft failure secondary to an improper shape. These cases demonstrate the potential beneficial applications for titanium cages in failed first ray reconstruction.

Surgical Treatment of Lisfranc Injury With Plantar Plate Approach

ABSTRACT Midfoot injuries are the second most common athletic foot injury documented in the published data. High‐energy Lisfranc dislocations are commonly seen secondary to traumatic etiologies and disrupt the strong midfoot ligaments supporting the arch. These injuries require immediate surgical intervention to prevent serious complications such as compartment syndrome and amputation. The present case series reports a new Lapidus plate system used in 3 patients who underwent arthrodesis procedures for Lisfranc joint dislocation. Three patients in their fourth to fifth decade of life presented with a traumatic injury at the Lisfranc joint and subsequently underwent open reduction and internal fixation using the plantar Lapidus Plate System (LPS; Arthrex, Naples, FL). The LPS was placed in a predetermined safe zone, with measures taken to avoid the insertional points of the tibialis anterior and peroneus longus tendons. Radiographs were obtained for ≤6 months postoperatively and revealed consolidation across the fusion site, intact hardware, and satisfactory alignment. On examination, the corrections were well maintained and free of signs of infection. Clinical evaluation showed no indication of motion within the tarsometatarsal joint and no tenderness to palpation surrounding the fusion sites. All 3 patients successfully returned to their activities of daily living without discomfort or pain. Modern surgical treatment of Lisfranc injuries most commonly includes open reduction and internal fixation, accompanied by arthrodesis. The present case series has demonstrated that the LPS provides relief, stability, and compression of the joint in our small cohort of patients who experienced a traumatic injury to the Lisfranc joint. Level of Clinical Evidence: 4

Pulmonary Pleomorphic Carcinoma Metastasis to the Midfoot

Metastases to the bones in the foot are extremely uncommon, occurring in approximately 0.01% of all metastatic bone disease. We describe a case of an 82-year-old female with a metastatic pulmonary sarcomatoid carcinoma lesion to the midfoot. This rare and aggressive pulmonary malignancy has a poor prognosis. The purpose of the present case report was to highlight the key roles that medical history and biopsy, combined with a multispecialty approach, play in accurately diagnosing and appropriately treating a patient with metastatic bone disease.