Stephen J. Pinney

The Effect on Ankle Dorsiflexion of Gastrocnemius Recession

Gastrocnemius equinus contracture has been suggested as an etiologic factor in mechanical diseases of the foot and ankle and in ulcer formation in the foot. The purpose of this study is to assess the correction in ankle dorsiflexion that can be achieved with a gastrocnemius recession. An isolated gastrocnemius release (Strayer procedure) was performed on 26 legs, in 20 consecutive patients, for clinically significant gastrocnemius equinus contracture. Ankle dorsiflexion was assessed using a validated electrogoniometer. Ankle dorsiflexion was recorded with the knee straight and with the knee bent. Measurements were recorded preoperatively, and immediately postoperatively. Measurements at an average of 55.0 days post-surgery (range, 37 to 128 days) were performed on 20 legs (15 patients). Results: Average preoperative ankle dorsiflexion with the knee straight was 5.1°. Average preoperative ankle dorsiflexion with the knee bent was 22.8°. Immediately following surgery the average ankle dorsiflexion with the knee straight was 23.2°. The average correction was 18.1° and this increase was significant (p < 0.0001.) In the 15 patients (20 legs) available for follow-up, the increase in ankle dorsiflexion with the knee straight was maintained (average: 24.9°). Patients with gastrocnemius contracture who underwent an isolated gastrocnemius release increased their ankle dorsiflexion (knee straight) by an average of 18.1° with postoperative ankle dorsiflexion (knee straight) being equivalent (23.2 and 22.8°) to preoperative ankle dorsiflexion (knee bent). This correction appears to be maintained (23.2 vs. 24.9°) at short-term follow-up.

Current concept review: acquired adult flatfoot deformity.

Acquired adult flatfoot deformity (AAFD) is a common and often debilitating chronic foot and ankle condition. AAFD is characterized by flattening of the medial longitudinal arch and dysfunction of the posteromedial soft tissues, including the posterior tibial tendon. Key46 described a chronic partial rupture of the posterior tibial tendon in 1953. Further descriptions of chronic posterior tibial tendon pathology began to identify an association between posterior tibial tendon dysfunction (PTTD) and flatfoot deformity.24,45,88 Initially, the condition was called PTTD; however, more recently it has become known as AAFD in recognition that the pathology encompasses more than just the posterior tibial tendon. The purpose of this review was to describe the key elements of AAFD and to outline treatment options based on the peer-reviewed literature. In keeping with the trend toward evidence-based practice, the level of evidence supporting each clinical research study has been reviewed. The idea behind assessing the level of evidence is that while each study constitutes evidence, some studies by virtue of their design are more persuasive than others.89 Recently, the AAOS developed the Level of Evidence table and Grades of Recommendation for the evaluation of studies and providing recommendations (Table 1).4–9

Current concept review: osteochondral lesions of the talus.

Osteochondral lesion of the talus (OLT) is a broad term used to describe an injury or abnormality of the talar articular cartilage and adjacent bone. Historically, a variety of terms have been used to refer to this clinical entity including osteochondritis dissecans, osteochondral fracture, and osteochondral defect. Currently, six characteristics are used to categorize a particular lesion (Table 2). An OLT can be described as chondral (cartilage only), chondral-subchondral (cartilage and bone), subchondral (intact overlying cartilage), or cystic. Lesions can then be subdivided as stable or unstable and non-displaced or displaced. The stability of a lesion can be assessed directly with arthroscopy or indirectly with MRI using DeSmet’s criteria.6 A lesion can also be categorized by its location on the articular surface of the talus as medial, lateral, or central with added subdivisions into anterior, central, or posterior as advocated by some authors.82 An additional description of identifying whether the lesion is contained or uncontained (shoulder) may also be included. Finally, although no accepted definition of lesion size exists, OLTs can generally be considered as either small or large based on their cross-sectional area or greatest diameter (area greater than or less than 1.5 cm2 or diameter greater than or less than 15 mm). Although these characteristics provide a scheme to classify OLTs and to select a therapeutic modality, they do not reliably predict the outcome of treatment. While the exact incidence of symptomatic OLTs is unknown, they are quite prevalent and are a significant

Surgical Anatomy and Accuracy of Percutaneous Achilles Tendon Lengthening

Background: Percutaneous Achilles tendon lengthening is frequently done to treat gastrocsoleus equinus contracture. To our knowledge, no study has documented the proximity of tendinous or neurovascular structures to the nearest edges of each hemisection in a percutaneous Achilles tendon lengthening, the complication rates related to injury of such structures, or the Achilles tendon rupture rates from inaccurate cuts. Thus, our goal was to document these distances and determine the accuracy of this procedure. Methods: We performed triple-hemisection percutaneous Achilles tendon lengthening (Hoke technique) in 15 cadaver specimens and documented the distance from each cut edge to various relevant anatomical structures. We also documented the accuracy of each cut (diameter of hemisection divided by total tendon diameter), with a reference goal of 50% transection at each level. Results: We found that percutaneous Achilles tendon lengthening is a relatively accurate procedure with hemisections averaging 50% for the middle cut and 60% at the most proximal cut, and 55% at the distal cut. Some tendinous and neurovascular structures are, on average, less than 1 cm from the nearest margin of a given hemisection and are, therefore, at risk. These included the flexor hallucis longus at the middle and proximal cuts (9.1 mm and 5.7 mm, respectively), the tibial nerve at the proximal cut (8.3 mm), and the sural nerve at the middle-lateral cut (7.9 mm). Conclusion: In cadavers, reasonably accurate cuts can be made, with some vital structures less than 1 cm from the cut tendon.

Are displaced talar neck fractures surgical emergencies? A survey of orthopaedic trauma experts.

Background: Displaced talar neck fractures are relatively rare injuries with potentially serious long-term morbidity. Expedient treatment has long been held as a treatment principle. The purpose of this study was to assess the current state of practice of treating displaced talar neck fractures by recognized orthopaedic trauma experts working at level 1 trauma centers. Methods: A group of expert orthopaedic trauma surgeons were surveyed to determine what they considered “the maximal acceptable time delay from injury to the operating room representing the minimal standard of care at a level 1 trauma center for a displaced talar neck fracture?” Each survey recipient had been selected as a moderator at a national orthopaedic trauma meeting during the past 5 years. Eighty-nine of 109 (82%) responded to the survey. Results: For a displaced talar neck fracture, 60% of respondents stated that treatment after 8 hours is acceptable, with 46% percent of respondents stating that treatment at or after 24 hours is acceptable. Conclusion: These results indicate that most expert orthopedic trauma surgeons do not believe that an immediate operation is necessary to adequately treat a displaced talar neck fracture.

Nonunion Risk Assessment in Foot and Ankle Surgery Proposing a Predictive Risk Assessment Model

Background: Nonunion risk factor identification and modification are subjective. We describe and validate a predictive nonunion risk factor model to identify foot and ankle operative patients at risk for nonunion. Materials and Methods: One hundred international experts in foot and ankle surgery were surveyed. Nineteen nonunion risk factors were stratified into 3 categories: more significant than, as significant as, and less significant than smoking 1 pack per day. A nonunion risk assessment model was developed by assigning a weighted score to each risk factor, based on its mean score from the survey. A total nonunion risk (TNR) score was calculated for individual patients. It was retrospectively validated in 2 patient cohorts from a single center’s prospectively collected end-stage ankle arthritis patient database: 22 cases of ankle and/or hindfoot fusion nonunion and 40 sex- and procedure-matched controls with bony fusion. Analyses included descriptive statistics, logistic regression, and univariate and multivariate linear regression models. Results: The mean TNR score was 6.6 ± 5.6 in controls and 13.5 ± 8.2 in the nonunion group (P < .001). Data showed excellent intraobserver and interobserver correlation coefficients. In a logistic regression model, the risk of nonunion exceeded 9% with a TNR score greater than or equal to 10. Multivariate linear regression analysis, adjusted for age and sex, suggested that lack of fusion site stability and obesity (body mass index greater than 30) were significantly predictive of nonunion. Conclusion: The nonunion risk assessment model provides a reliable, sensitive, and specific method for predicting nonunion based on objective patient assessment. Orthopaedic patients at risk for nonunion could benefit from targeted intervention. Level of Evidence: Level IV, retrospective observational study.

Madura foot (Madurella Mycetoma) presenting as a plantar fibroma : A case report

Well-circumscribed plantar masses are common. Most are caused by plantar fibromatosis. Ledderhose4 first described plantar fibromatosis as a distinct disease in 1897. Clinically, the lesions of plantar fibromatosis tend to remain asymptomatic for long periods and occur as one or more firm, fixed subcutaneous nodules on the plantar aspect of the foot. Symptoms may result from a mass effect or from local invasion of muscles or neurovascular structures.5 Treatment of locally invasive plantar fibromas consists of operative excision with wide margins to prevent recurrence. Experienced orthopaedic surgeons base their diagnosis of plantar fibromatosis on physical examination findings. MRI can be helpful to rule out a more aggressive soft-tissue tumor. This case report describes a plantar mass with clinical and MRI presentations characteristic of plantar fibroma that subsequently proved to be a mycetoma of the foot (Madura foot). Madura foot is a localized, chronic, progressive infection of the skin and subcutaneous tissues, usually containing abscesses, granulomata, or both. Bone involvement is common. The infection is characterized by sinus track formation, induration, and the presence of colonies manifesting as grains and granules.3 These grains and granules are vegetative aggregates of the bacterial or fungal etiologic agent (Figure 1).

Current Concepts Review Update: Osteochondral Lesions of the Talus

Osteochondral lesions are pathologic entities affecting the articular cartilage and subchondral bone. In 1887, Franz König first hypothesized the potential etiologies for loose bodies coming from the articular surfaces of various joints. These lesions were originally referred to as osteochondritis dissecans. König stated that these injuries were most commonly a result of severe trauma, though they may occasionally be due to spontaneous compromise of cartilage and the underlying subchondral bone. Osteochondritis dissecans of the ankle, now commonly referred to as osteochondral lesions of the talus (OLT), was first described by Kappis in 1922. Since the initial description, these entities have been increasingly studied and understood, and it is currently estimated that the incidence rate of these lesions is 27 per 100 000 person-years among the active military population. Initially establishing the diagnosis of OLT can be challenging. Patients may present with prolonged pain, swelling, and catching following traumatic injuries to the ankle or after seemingly innocuous incidents. However, many OLTs also arise without specific trauma, and may be related to repetitive injury. Others are asymptomatic and found incidentally on plain radiographs or advanced imaging. In patients who are symptomatic, identification of OLTs through radiographs can be challenging because these lesions are not always immediately evident, and thus further imaging modalities are often required to confirm the diagnosis. Computed tomography (CT) or magnetic resonance imaging (MRI) can help identify both the location and severity of the lesion. Because of the increasing awareness of these entities, as well as recent advances in both nonoperative and operative approaches to care, we present an updated current concepts review of the literature on diagnosis and evidence-based recommendations for the treatment of osteochondral lesions of the talus.

Perceived risk factors for nonunion following foot and ankle arthrodesis

Background: A major complication of foot and ankle arthrodesis is nonunion, which occurs in approximately 12% of cases. Various factors influence a patient’s risk for nonunion following foot and ankle arthrodesis. We surveyed international foot and ankle surgeons to determine (1) risk factors perceived most important for nonunion, (2) factors considered absolute contraindications for arthrodesis, and (3) differences among expert groups regarding perceived risk factors and their stratification. Methods: A questionnaire was e-mailed to members of a major foot and ankle journal editorial board and four foot and ankle society executive committees. The relative risk of 18 potential nonunion risk factors was rated from 1 to 10, using smoking 1 pack/day as a benchmark score of 5.00. Results: The response rate was 72% (100/139); 81% declared foot and ankle surgery encompasses >90% of their practice. The highest perceived risk factors (p < 0.001) were smoking 2 packs/day (mean score 8.69), lack of fusion site stability (8.66), and poor local vascularity (7.66). The least important risk factors (p < 0.001) were perceived to be age >60 years (mean score 2.54), rheumatoid arthritis (3.05), and osteoporosis (3.56). The most frequently cited absolute contraindications to arthrodesis surgery were local infection (46%), poor local vascularity (41%), and smoking (32%). Conclusion: To improve arthrodesis outcomes, resource allocation and patient and surgeon education should focus on smoking, construct stability, and local vascularity. Development of an objective nonunion risk assessment tool to identify patients at risk for nonunion using these results could help maximize the efficiency of available resources.

Special report: Highlights of the Twenty-Fourth Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society, Denver, Colorado, June 26–28, 2008

The Twenty-Fourth Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society (AOFAS) was held 26-28 June 2008 at the Denver Marriott City Center in Denver, Colorado. There were 442 registrants in attendance, including 81 individuals from 21 countries outside the United States. There were 176 abstracts submitted, and 46 (26%) abstracts were accepted for podium presentation.