Steven L. Haddad

Surgeon Training and Complications in Total Ankle Arthroplasty

Background: This study assessed the problems with initial use of ankle arthroplasty by surgeons who were trained by observing the surgeon/inventor (group I), who have completed a structured, hands-on surgical training course (group II), or who were trained during a 1-year foot and ankle fellowship (group III). Materials and Methods: The perioperative records of the first 10 cases of nine surgeons were reviewed. We evaluated the 6-month-postoperative standing mortise and lateral radiographs for evidence of syndesmosis union and accuracy of tibial component implantation. Three surgeons were each in group I, group II, and group III. Average patient age at time of surgery was similar. Ankle arthritis was classified as rheumatoid arthritis (RA) or osteoarthritis (OA) as follows: group I (7 RA, 23 OA), group II (7 RA, 23 OA), and group III (3 RA, 27 OA). Results: In group I, there were nine intraoperative complications, four postoperative wound dehiscences, and three postoperative deep infections. Radiographic evaluation of the 26 cases with adequate postoperative roentgenograms revealed that 10/26 (38%) had a delayed union of the syndesmosis. In group II, there were six intraoperative complications and two postoperative wound problems: an early anterior wound problem and a delayed lateral wound breakdown. Radiographic evaluation of the 26 cases with adequate postoperative roentgenograms revealed that 13/26 (50%) had a delayed union of the syndesmosis. In group III, there were four intraoperative complications and four postoperative wound problems – all healed with local supportive care with one requiring lateral hardware removal. Radiographic evaluation of the 26 cases with adequate postoperative roentgenograms revealed that 5/30 (17%) had a delayed union of the syndesmosis. The initial series from these three groups are statistically indistinguishable with respect to rates of complications, revisions, or malalignment. Conclusion: No identified training method had a statistically demonstrable positive impact on preparing surgeons for performing total ankle replacement. Some of these findings are likely generic for total ankle replacements and not restricted to any class or design of implant. Surgeon initial use of total ankle replacement needs to be done with caution and serious consideration.

Results of Flexor-to-Extensor and Extensor Brevis Tendon Transfer for Correction of the Crossover Second Toe Deformity

Between 1990 and 1995, 38 patients (42 feet) underwent repair for crossover toe deformity, 31 (35 feet) of whom returned for final examination at an average of 51.6 months (range, 24–81 months). Causes included trauma, iatrogenic, and unknown. Presenting complaints included dorsal pain with either metatarsalgia or joint pain, isolated metatarsophalangeal (MP) joint pain, metatarsalgia, painful plantar callus, metatarsalgia and joint pain, and painful dorsal callus. All patients were treated with one of two operative techniques, either the flexor-to-extensor tendon transfer or the extensor brevis tendon transfer. Choice of procedure depended on the stage of preoperative deformity. Twenty-four patients were completely satisfied with the surgical correction, 6 were satisfied with reservations, and 1 was dissatisfied. The average postoperative AOFAS score for all patients was 85 points (range, 54–100 points), which correlated strongly with patient satisfaction. Twenty-two patients stated that they had no postoperative pain, 8 reported some pain, and 1 had frequent pain at the corrected toe. In 30 feet, there was no recurrence; three patients had mild residual crossover toe deformity, and two patients had recurrent deformity, although all MP joints were stable. Follow-up radiographs demonstrated substantial reduction in MP joint angles in both the AP (from 7° to −1°) and lateral (from 45° to 25°) projections. This article reviews the surgical technique of both procedures, proposes specific indications for each, and presents outcomes. Based on our findings, the extensor brevis tendon transfer is appropriate for stage 1, stage 2, and flexible stage 3 deformities. Flexor-to-extensor tendon transfer is appropriate for rigid stage 3 and stage 4 deformities and for all patients with a symptomatic neuroma of the second web space (where the extensor brevis transfer is not possible). Stiffness of the MP joint is a potential problem with the flexor-to-extensor tendon transfer.

Evaluation of Periprosthetic Lucency After Total Ankle Arthroplasty: Helical CT Versus Conventional Radiography

Background: Osteolysis after total ankle arthroplasty (TAA) has become a major concern regarding long-term implant survival. The primary goal of this study was to determine whether CT was more sensitive than plain films in detecting the presence and extent of periprosthetic lucency. A secondary goal was to determine whether lack of syndesmotic fusion was associated with more extensive lucency. Methods: Seventeen patients (19 ankles) who had TAA between 2001 and 2003 were consecutively recruited and evaluated as part of a prospective study. Plain radiographs and helical CT with metal-artifact minimization were obtained. Evidence of lucent lesions and syndesmotic fusion was compared using the different imaging techniques. Results: Of the 19 ankles imaged, a total of 29 lesions were detected by CT, whereas plain radiographs detected 18 lesions. CT detected 21 lesions less than 200mm 2 , of which plain radiographs detected only 11. The mean size of the lesions detected on CT was over three times larger than the size on plain radiographs. With the small sample size used, there were no statistically significant differences between ankles with and without fusion of the syndesmosis and the extent (p = 0.84) and location (p = 0.377) of lucency. Conclusion: CT is a more accurate method for early detection and quantification of periprosthetic lucency than plain radiographs. Accurate evaluation of lucent lesions may identify patients at high risk for lack of syndesmotic fusion with subsequent loosening and implant failure.

Subtalar instability: Etiology, diagnosis, and management

Subtalar instability is an evolving disorder that seems to cause a portion of chronic hindfoot instability. It can be seen as an isolated problem, or more commonly, in combination with ankle instability. There seems to be many injury mechanisms, most of which seem to involve supination of the hindfoot, and all seem to attenuate the lateral ligaments of the ankle and subtalar joints. As the condition progresses, and additional sprains occur as a result of the alteration in subtalar joint mechanics, the remaining ligaments become attenuated. There are many methods described to diagnose subtalar instability, but no conclusive test has been devised. Thus, the diagnosis must be inferred from an accurate history, physical examination, conferring radiographic studies, and failure of nonoperative management (often, for ankle instability). As with other hindfoot injuries, many patients improve with conservative measures. These measures are early (ice and immobilization) and late (bracing and proprioceptive training). When patients do not improve or cannot tolerate bracing, recent studies have shown there is a role for ligamentous reconstruction. Most procedures attempt to recreate the lateral ligament structures, including the calcaneofibular, the cervical, and the interosseous talocalcaneal ligaments, which seem to have the best stabilizing effect on the hindfoot. With the advent of newer procedures and more aggressive surgical management, there may be a role for early anatomic repair and rehabilitation.

Deltoid Ligament Reconstruction: A Novel Technique with Biomechanical Analysis

Background: Deltoid ligament insufficiency has been shown to decrease tibiotalar contact area and increase peak pressures within the lateral ankle mortise. This detrimental effect may create an arthritic ankle joint if left unresolved. Reconstructive efforts thus far have been less than satisfactory. We describe a novel technique that reconstructs both main limbs of the deltoid ligament in anatomic orientation while providing secure graft fixation. Materials and Methods: Six pairs of fresh frozen cadaveric lower extremities were utilized. Matched right and left lower limbs (one pair) were allocated either to a deltoid reconstruction group or an intact deltoid group. The anterior tibial tendon was chosen as the graft for ligament reconstruction, and was harvested from the ipsilateral specimen. Tunnels were created in the distal tibia at the deltoid origin, and at the talus (deep) and calcaneus (superficial) deltoid insertions. Following measurement, the graft was cut to the appropriate size and endobuttons weaved into both tendon ends. The graft ends were passed through the talus and calcaneus respectively. The residual graft loop was then routed through the tibial tunnel and secured proximally with a cancellous screw post and spiked washer. Following specimen mounting, a multiaxis testing apparatus with three separate motors allowed three planes (dorsiflexion/plantarflexion; inversion/eversion; and internal/external rotation) of motion. Angular rotations and linear translations of the tibia in the X-Y-Z directions were measured for a given torque in external/internal rotation, dorsiflexion/plantarflexion, or eversion/inversion, under a constant velocity of 2 degrees per second. Testing consisted of a 2 Nm preload for 20 cycles in internal rotation/external rotation and inversion/eversion prior to data collection of 10 cycles at this level of torque. Similarly, a preload of 1 Nm for 20 cycles was used in dorsiflexion/plantarflexion prior to data collection of 10 cycles at this torque level. Data were collected in the control specimens (the matched contralateral extremity) with the deltoid ligament intact, and following complete sectioning of the ligament complex (both bundles). Results: Angular displacement at a 2 Nm level torque was significantly greater in the sectioned group compared to the deltoid reconstruction group in external rotation and eversion (p = 0.006 and p = 0.017 respectively). There was no statistical difference in angular displacement between the deltoid intact and reconstructed group in external rotation and eversion when tested at 2 Nm of torque (p = 0.865 and p = 0.470, respectively). The stiffness of the reconstruction was 136.4 ± 40.2% compared to the intact ligament. Stiffness data were statistically insignificant in both plantar flexion and dorsiflexion between the reconstructed and sectioned groups (p = 0.050 and p = 0.126). Conclusion: The described reconstruction technique under low torque was able to restore eversion and external rotation stability to the talus, which was statistically similar to the intact deltoid ligament. This novel technique developed its strength not only from the anatomic orientation of the reconstructed ligament, but the strength of the components chosen to fix the tendon graft to the bone. Clinical Relevance: This utilitarian reconstruction may be incorporated into total ankle arthroplasty, triple arthrodesis, and sports injuries to re-establish lost medial stability.

Impact of talar component rotation on contact pressure after total ankle arthroplasty: a cadaveric study.

Background: There is limited literature available to assess the impact of talar component rotation on total ankle contact biomechanics. Materials and Methods: Six male cadaveric below-knee specimens were implanted with Agility® total ankles. The sequence of talar rotation for each specimen was randomized between: Neutral, 7.5 degrees internal and 7.5 degrees external rotation. Contact pressure was measured using Tekscan ankle sensors during sequential static axial loadings and 10 simulated dynamic strides under 650 N axial load. Results: The peak pressure (PP) increased for the internally (PPstatic = 7.0 ± 0.27 MPa (mean ± SD), p < 0.001; PPdynamic = 7.8 ± 0.22 MPa, p = 0.001) and externally rotated talar component positions (PPstatic = 6.2 ± 0.22 MPa, p = 0.011; PPdynamic = 7.6 ± 0.29 MPa,p = 0.004) as compared to neutral (PPstatic = 5.5 ± 0.13 MPa; PPdynamic = 6.3 ± 0.11 MPa). The contact area under 650 N load was reduced for both talar component internal (97.38 ± 17.7 mm2, p = 0.001) and external rotation (152.66 ± 16.8 mm2, p = 0.022) as compared to neutral (190.02 ± 13.8 mm2). There was a significant rotational torque for the malrotated talar components as compared to neutral, that increased with axial loading (p = 0.044). Conclusion: Near the extremes of talar malrotation, there was a consistent change from a continuous tibiotalar contact area to a pattern of two-point contact; the orientation of which opposed the direction of talar component malrotation. Talar component malrotation resulted in: increased peak pressure, decreased contact area and increased rotational torque that resisted the malrotation. Clinical Relevance: Talar component malrotation may contribute to premature polyethylene wear as well as potential talar loosening secondary to the rotational torque generated as the geometry of the prosthesis attempts to seek congruency.

Tenosynovitis of the posterior tibial tendon

PTT tenosynovitis is a recognized entity no longer confused with an ankle sprain. Three possible causes are (1) overuse or age related (mechanical in cause, true stage I disease), (2) seronegative spondyloarthropathies (clinical suspicion, hematologic analysis), and (3) rheumatoid arthritis (deformity may be owing to ligamentous or capsular destruction). The PTT has a hypovascular zone 40 mm proximal to the insertion of the tendon and 14 mm in length. Pain often is localized to this portion of the tendon (primarily in stage I disease). Ultrasound is an inexpensive and accurate method to assist in the diagnosis of this condition and may replace MR imaging as more experienced ultrasonographers appear. The initial management of PTT tenosynovitis includes tendon rest and nonsteroidal anti-inflammatory medication and physical therapy. Surgical synovial débridement is performed early (6 weeks) in patients with enthesopathies (seronegative disease). This procedure may be delayed 3 months in patients with true stage I disease. At surgery, the undersurface of the tendon must be inspected for longitudinal split tears, and these must be repaired with nonabsorbable suture, burying the knots. The excursion of the tendon should be checked intraoperatively. Patients with stage I disease should be evaluated carefully for preoperative structural deformity to choose the appropriate surgical procedure and prevent failure of isolated tenosynovectomy.

The Strength of Achilles Tendon Repair: A Comparison of Three Suture Techniques in Human Cadaver Tendons:

Background: A previous study suggests the double Krackow suture (locking-loop) weave technique is nearly twice as strong as the single Bunnell or single Kessler suture repair techniques. Our hypothesis was that the strength of different repair techniques would be comparable if a similar number of suture strands cross the repair site. Materials and Methods: Twenty-four fresh-frozen human cadaver Achilles tendons were used to test maximum strength of three suture techniques (double Bunnell, double Kessler, and double Krackow). The simulated ruptures were created in the midsubstance of the Achilles tendon, five centimeters proximal to its calcaneal insertion. All repairs were performed with No. 2 polyester (Mersilene, Ethicon, Sommerville, NJ) nonabsorbable suture in standard fashion for each technique, with four strands crossing the repair site. The tendons were then anchored to a materials testing machine (Instron, Canton, MA) through a calcaneal pin distally and a modified soft tissue clamp proximally. Tendons were loaded with continuous tension at a head speed of 0.85 cm/s. Results: All repairs failed at the site of the suture knots, none pulling out through the substance of the tendon. A one-way analysis of variance was performed on the maximum force at failure of each repair technique. No statistically significant difference was noted between the double Krackow weave (199.9 ± 20 N), the double Bunnell weave (196.2 ± 45 N), and the double Kessler weave (166.9 ± 51 N). Conclusion: We found that in a laboratory model of cadaveric Achilles tendon repairs there was no significant difference in strength between the Krackow, Bunnell, and Kessler suture techniques, when each was performed with a double suture weave. Clinical Relevance: This is a cadaveric study that attempts to simulate the clinical parameters of Achilles tendon ruptures, repairs, and repair failures to examine the strength of different repair techniques.

Adult Acquired Flatfoot Deformity

Most of the controversy surrounding management of the adult acquired flatfoot deformity revolves around the correction of Stage II deformity. Stage I deformity, uncommonly corrected surgically, involves tenosynovitis with preservation of tendon length and absence of structural deformity. Attempts at tenosynovectomy in light of structural deformity leads to operative failure, found in 10% of Teasdall and Johnson’s 1992 patient population. Thus, with tenosynovectomy rarely becoming an operative situation, Stage II deformity is the most common problem requiring operative treatment of the adult flatfoot. Stage II deformity patients present with swelling medially, the inability to do a single heel raise, with a passively correctable subtalar joint. The tendon is functionally torn. In recent years, authors have subdivided Stage II deformity even further into A and B subcategories, where A involves less than 50% uncovering of the talonavicular joint, and B more than 50%. Recently, Anderson has added a C subtype, which may be applied to either A and B patients, in patients who have forefoot varus. Thus, Stage II patients suffer from pain that begins medially and progresses to the subfibular region over time. Most important, recognition of the continued sub-classification in Stage II disease echoes the fact that this disorder is on a continuum, challenging the surgeon to recognize subtleties that, if unrecognized, lead to a poor patient outcome. In this review, Myerson discusses treatment in Stage II disease with the medial slide calcaneal osteotomy, which realigns the hindfoot axis reducing valgus, improves the

Early Clinical and Radiographic Outcomes of Intramedullary-Fixation Total Ankle Arthroplasty

BACKGROUND The present study evaluated the early clinical outcomes, radiographic parameters, and survivorship of first and second-generation INBONE intramedullary-fixation total ankle arthroplasties. METHODS Fifty-nine primary total ankle arthroplasties utilizing INBONE I or II implants were performed in fifty-nine patients (thirty-one men and twenty-eight women; mean age, 57.2 years) from 2008 to 2012. The AOFAS (American Orthopaedic Foot & Ankle Society) ankle-hindfoot score and VAS (visual analog scale) pain score were recorded preoperatively and at the time of the latest follow-up. Weight-bearing radiographs were used to determine ankle motion and assess component alignment and subsidence. Intraoperative and postoperative complications, reoperations, and failures were evaluated. RESULTS All fifty-nine patients were available for follow-up at least two years after surgery; the mean follow-up duration was 35.0 ± 11.9 months. The estimated survival rate at two years was 96.6% in the entire cohort (91.3% in the INBONE I group and 100% in the INBONE II group) when revision of the tibial and/or the talar component was used as the end point. The mean AOFAS ankle-hindfoot score improved from 44.1 to 87.3 at the time of the latest follow-up (p < 0.01), and the mean VAS pain score improved from 8.1 to 1.6 (p < 0.01). Mean total ankle motion improved from 29.0° to 38.0° (p < 0.01). Fourteen patients (24%) required a reoperation because of a postoperative complication. Five of these patients (four with INBONE I implants and one with INBONE II implants; 8% of the entire cohort) required revision surgery at a mean of 32.4 months (range, fifteen to fifty-eight months) because of symptomatic talar subsidence. Talar revisions utilized an INBONE II implant with a pegged talar sulcus for definitive management. The patients who underwent revision surgery had mean total ankle motion of 41.6°, neutral alignment, and no further reoperations at the time of the latest follow-up. CONCLUSIONS Early results of INBONE intramedullary-fixation total ankle arthroplasty demonstrated improved patient-reported outcomes and increased ankle motion at a minimum follow-up of two years. Arthrofibrosis and talar subsidence were the main postoperative complications that required revision, and these predominantly affected the first-generation INBONE I implants.