Steven M. Raikin

Osteochondral Lesions of the Talus: Localization and Morphologic Data from 424 Patients Using a Novel Anatomical Grid Scheme

Background: The primary aim of this study was to evaluate the true incidence of osteochondral lesions on the talar dome by location and by morphologic characteristics on MRI. Because no universally accepted localization system for talar dome osteochondral lesions currently exists, we established a novel, nine-zone anatomical grid system on the talar dome for an accurate depiction of lesion location. Methods: We assigned nine zones to the talar dome articular surface in an equal 3 × 3 grid configuration. Zone 1 was the most anterior and medial, zone 3 was anterior and lateral, zone 7 was most posterior and medial, and zone 9 was the most posterior and lateral. The grid was designed with all nine zones being equal in surface area. Two observers reviewed MRI examinations of 428 ankles in 424 patients (211 males and 213 females; mean age 43 years; age range 6 to 85 years) with reported osteochondral talar lesions. We recorded the frequency of involvement and size of lesion for each zone. Statistical analyses were performed using ANOVA and Scheffe tests. Results: Four hundred and twenty-eight lesions were identified on MRI. The medial talar dome was more frequently involved (n = 269, 62%) than the lateral talar dome (n = 143, 34%). In the AP direction, the mid talar dome (equator) was much more frequently involved (n = 345, 80%) than the anterior (n = 25, 6%) or posterior (n = 58, 14%) thirds of the talar dome. Zone 4 (medial and mid) was most frequently involved (n = 227, 53%), and zone 6 (lateral and mid) was second most frequently involved (n = 110, 26%). Lesions in the medial third of the talar dome were significantly larger in surface area involvement and deeper than those at the lateral talar dome. Conclusions: Our established nine-grid scheme is a useful tool for localizing and characterizing osteochondral talar lesions, which are most frequently located in zone 4 at the medial talar dome, and second most in zone 6 at the lateral talar dome near its equator. Medial talar dome lesions are not only more common but are larger in surface area and in depth than lateral lesions. Posteromedial and anterolateral lesions rarely were found.

Comparison of arthrodesis and metallic hemiarthroplasty of the hallux metatarsophalangeal joint

BACKGROUND Currently, arthrodesis is the most commonly performed surgical procedure for the treatment of severe arthritis of the first metatarsophalangeal joint. The objective of this study was to compare the long-term clinical and radiographic outcomes of a metallic hemiarthroplasty with those of arthrodesis for the treatment of this condition. METHODS A series of patients with osteoarthritis of the first metatarsophalangeal joint were treated with either a metallic hemiarthroplasty or an arthrodesis between 1999 and 2005. Postoperative satisfaction and function were graded with use of the American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal Interphalangeal (AOFAS-HMI) scoring system, and pain was scored with use of a visual analogue scale. RESULTS Twenty-one hemiarthroplasties and twenty-seven arthrodeses were performed in forty-six patients. Five (24%) of the hemiarthroplasties failed; one of them was revised, and four were converted to an arthrodesis. Eight of the feet in which the hemiprosthesis had survived had evidence of plantar cutout of the prosthetic stem on the final follow-up radiographs. At the time of final follow-up (at a mean of 79.4 months), the satisfaction ratings in the hemiarthroplasty group were good or excellent for twelve feet, fair for two, and poor or a failure for seven. The mean pain score was 2.4 of 10. All twenty-seven of the arthrodeses achieved fusion, and no revisions were required. At the time of final follow-up (at a mean of thirty months), the satisfaction ratings in this group were good or excellent for twenty-two feet, fair for four, and poor for one. The mean pain score was 0.7 of 10. Two patients required hardware removal, which was performed as an office procedure with the use of local anesthesia. The AOFAS-HMI and visual analogue pain scores and satisfaction were significantly better in the arthrodesis group. CONCLUSIONS Arthrodesis is more predictable than a metallic hemiarthroplasty for alleviating symptoms and restoring function in patients with severe osteoarthritis of the first metatarsophalangeal joint.

Effect of nicotine on the rate and strength of long bone fracture healing.

Empirical clinical observation suggests that cigarette smoking has an inhibitory effect on long bone fracture healing, but this has not been proven scientifically. Forty female New Zealand White rabbits had midshaft tibial osteotomies performed and plated. These were divided randomly into two groups receiving either systemic nicotine or saline (placebo). Lateral radiographs were taken at 4, 6, and 8 weeks that showed a 17.2% average difference in callus formation between the two groups and a significant lag in formation of cortical continuity in the nicotine group. The rabbits were sacrificed 8 weeks after fracture, and healing was compared biomechanically. Three (13%) fractures showed no clinical evidence of union in the nicotine group, whereas all fractures in the control group healed. Biomechanical testing showed the nicotine exposed bones to be 26% weaker in three-point bending than were those exposed to placebo.

Fresh Osteochondral Allografts for Large-Volume Cystic Osteochondral Defects of the Talus

BACKGROUND Large-volume osteochondral lesions of the talus present a difficult dilemma for the treating physician. The purpose of this study was to evaluate the clinical outcomes of talar lesions with a volume of >3000 mm(3) treated with fresh bulk osteochondral allograft transplantation. METHODS Fifteen patients (mean age, 41.9 years) who had symptomatic osteochondral lesions of the talus with a mean volume of 6059 mm(3) underwent fresh matched osteochondral allograft transplantation. All patients were followed prospectively for a minimum of two years and were evaluated with use of the pain score on a visual analog scale, which ranged from 0 to 10, and the American Orthopaedic Foot and Ankle Society ankle-hindfoot score, which had a maximum of 100 points. Patient satisfaction and radiographic stability of the graft were also assessed. RESULTS All patients were available for follow-up at an average fifty-four months after surgery. Two ankles subsequently underwent conversion to an ankle arthrodesis at thirty-two and seventy-six months, respectively. With the scores for these patients included (at the time of arthrodesis), the mean pain score had improved from 8.5 to 3.3 and the mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score had improved 45 points, from 38 to 83 points. Overall, five patients rated the result as excellent, six as good, two as fair, and two as poor. CONCLUSIONS Bulk fresh osteochondral allograft transplantation to the talus is a viable reconstructive option for patients with large-volume cystic lesions of the talar dome. Graft stability and viability are maintained both structurally and functionally over a mean follow-up period of 4.5 years (minimum, two years).

Risk factors for wound complications after ankle fracture surgery.

BACKGROUND The overall rate of complications after ankle fracture fixation varies between 5% and 40% depending on the population investigated, and wound complications have been reported to occur in 1.4% to 18.8% of patients. Large studies have focused on complications in terms of readmission, but few studies have examined risk factors for wound-related issues in the outpatient setting in a large number of patients. A review was performed to identify risk factors for wound complications tracked in the hospital and outpatient setting. METHODS Four hundred and seventy-eight patients underwent open reduction and internal fixation of an ankle fracture between 2003 and 2010 by a single surgeon at a single institution. Demographic characteristics, time to surgery, comorbidities, and postoperative care were tracked. Wound complications were defined as those requiring dressing care and oral antibiotics or requiring further surgical treatment. RESULTS Of the 478 patients who were followed, six (1.25%) had wounds requiring surgical debridement. Fourteen patients (2.9%) required further dressing care or a course of oral antibiotics. There were significant associations between wound complications and a history of diabetes (p < 0.001), peripheral neuropathy (p = 0.003), wound-compromising medications (p = 0.011), open fractures (p = 0.05), and postoperative noncompliance (p = 0.027). There was a significant difference in age between patients with and without wound complications (p = 0.045). We did not identify a relationship between time to surgery and complications. CONCLUSIONS These results highlight the difficulty of treating medically complex and noncompliant patient populations. With careful preoperative monitoring of swelling, time to surgery does not affect wound outcome. The failure of the patient to adhere to postoperative instructions should be a concern to the treating surgeon.

Prediction of Midfoot Instability in the Subtle Lisfranc Injury: Comparison of Magnetic Resonance Imaging with Intraoperative Findings

BACKGROUND The objective of the present study was to assess the utility of magnetic resonance imaging for the diagnosis of an injury to the Lisfranc and adjacent ligaments and to determine whether conventional magnetic resonance imaging is a reliable diagnostic tool, with manual stress radiographic evaluation with the patient under anesthesia and surgical findings being used as a reference standard. METHODS Magnetic resonance images of twenty-one feet in twenty patients (ten women and ten men with a mean age of 33.6 years [range, twenty to fifty-six years]) were evaluated with regard to the integrity of the dorsal and plantar bundles of the Lisfranc ligament, the plantar tarsal-metatarsal ligaments, and the medial-middle cuneiform ligament. Furthermore, the presence of fluid along the first metatarsal base and the presence of fractures also were evaluated. Radiographic observations were compared with intraoperative findings with respect to the stability of the Lisfranc joint, and logistic regression was used to find the best predictors of Lisfranc joint instability. RESULTS Intraoperatively, seventeen unstable and four stable Lisfranc joints were identified. The strongest predictor of instability was disruption of the plantar ligament between the first cuneiform and the bases of the second and third metatarsals (the pC1-M2M3 ligament), with a sensitivity, specificity, and positive predictive value of 94%, 75%, and 94%, respectively. Nineteen (90%) of the twenty-one Lisfranc joint complexes were correctly classified on magnetic resonance imaging; in one case an intraoperatively stable Lisfranc joint complex was interpreted as unstable on magnetic resonance imaging, and in another case an intraoperatively unstable Lisfranc joint complex was interpreted as stable on magnetic resonance imaging. The majority (eighteen) of the twenty-one feet demonstrated disruption of the second plantar tarsal-metatarsal ligament, which had little clinical correlation with instability. CONCLUSIONS Magnetic resonance imaging is accurate for detecting traumatic injury of the Lisfranc ligament and for predicting Lisfranc joint complex instability when the plantar Lisfranc ligament bundle is used as a predictor. Rupture or grade-2 sprain of the plantar ligament between the first cuneiform and the bases of the second and third metatarsals is highly suggestive of an unstable midfoot, for which surgical stabilization has been recommended. The appearance of a normal ligament is suggestive of a stable midfoot, and documentation of its integrity may obviate the need for a manual stress radiographic evaluation under anesthesia for a patient with equivocal clinical and radiographic examinations.

The modified use of a proximal humeral locking plate for tibiotalocalcaneal arthrodesis

Background: Different types of fixation have been used to achieve a tibiotalocalcaneal (TTC) arthrodesis. The purpose of this study was to retrospectively examine the modified use of a 3.5-mm proximal humeral locking plate (PHILOS plate, Synthes, Paoli, PA) in obtaining a TTC fusion. Methods: Between April, 2003, and November, 2005, 17 patients had 18 TTC arthrodeses with a PHILOS plate through a transfibular approach. Preoperative diagnoses included Charcot arthropathy, neuromuscular disease, arthritis, and talar osteonecrosis. Patients were followed from 8 months to 3 years and 2 months (mean 20.6 months). Results: Fusion was achieved in 16 of the 17 patients (94.1%) and 17 of the 18 arthrodeses (94.4%) with a mean time to fusion of 20.6 weeks. The mean American Orthopaedic Foot and Ankle Society (AOFAS) score increased from 14.6 of 100 preoperatively to 76.7 of 86 (equivocal to 89.2 of 100) at final followup. One patient who had brittle diabetes went on to develop a nonunion. Conclusions: The patients in this study had a wide variety of medical conditions that left their bone osteopenic or osteoporotic. This study demonstrated that using a modified locking plate for a TTC arthrodesis results in a high rate of bony union and alignment correction stability. The locking plate provides fixation by acting as a fixed angle device, with the locking screws providing multiplanar fixation. The use of a locking plate has not been previously reported, and it may hold promise as a means of achieving a TTC fusion.

Osteochondral lesions of the talus: change in MRI findings over time in talar lesions without operative intervention and implications for staging systems.

Background: MRI findings are used in several staging systems to help determine appropriate treatment. The purposes of this study were to evaluate longitudinal changes in MRI characteristics of osteochondral lesions of the talus (OLT) and to evaluate published staging systems in a cohort of nonoperatively treated patients. Methods: Twenty-nine patients were identified; MR images were reviewed for location, size, and interface signal of OLT as well as cysts, marrow edema and osteoarthritis. Lesions were classified as unchanged, progressed, or improved based on changes in size or interface signal. Each lesion was assigned a stage based on four different staging systems. Results: Of the 29 lesions, 13 progressed, seven improved, and nine were unchanged over an average followup of 13.7 months. In the 13 that progressed, marrow edema remained present in ten and developed in two. Four had persistent cysts and four developed new cysts. Two had progression of osteoarthritis and two developed it anew. In the seven that improved, six had some degree of marrow edema that persisted and one had a persistent cyst. Initial staging changed for at least one classification system in 16 (55%) of the 29 lesions at followup. Change in stage was primarily due to development (four of 16) or disappearance of cysts or progression of the lesion in the extent of bone marrow edema (five of 16). Conclusions: OLT did not invariably progress over the short-term without operative intervention. Because some cysts and bone marrow edema resolved on MRI, they may not be reliable signs of lesion severity nor show progression of degenerative changes. Since these findings determine the stage and severity of OLT in some staging systems, they may require reconsideration and adjustment of the current staging systems.

Reconstruction for Missed or Neglected Achilles Tendon Rupture with V-Y Lengthening and Flexor Hallucis Longus Tendon Transfer through One Incision

Background: The purpose of this study was to introduce a novel operative technique and to evaluate the clinical outcomes in a cohort of patients with missed or neglected Achilles tendon ruptures. Methods: Fifteen consecutive patients with missed complete Achilles tendon ruptures and 5-cm or larger gaps had reconstruction with V-Y lengthening and flexor hallucis longus tendon transfer through a single incision. The patients were evaluated at an average of 106 weeks after surgery. At the time of followup, all patients were assessed with regard to their self-reported level of satisfaction and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. Ankle strength and active range of motion were evaluated using Biodex® (Biodex Medical Systems, Shirley, NY) isokinetic dynamometry. In addition, seven patients were evaluated using diagnostic ultrasound. Results: We found a 7.7 N-m (–22.3%) loss of plantarflexion torque at 60 degrees/sec and a 3.5 N-m (–13.5%) loss of plantarflexion torque at 120 degrees/sec, as well as a 5 degrees loss of active range of motion. AOFAS scores were all good to excellent, with an average score of 94.1 of 100. All patients were satisfied with their outcomes (rated good or very good). Excellent exposure of the Achilles tendon repair was obtained with ultrasound. Conclusions: For patients with missed or neglected Achilles tendon rupture with a rupture gap of at least 5 cm, operative repair using V-Y lengthening and flexor hallucis longus tendon transfer through a single incision technique achieved a high percentage of satisfactory results.

Achilles Tendon Injuries in a United States Population

Background: Most studies on Achilles tendon ruptures involved US military or European populations, which may not translate to the general US population. The current study reviews 406 consecutive Achilles tendon ruptures occurring in the general US population for patterns in a tertiary care subspecialty referral setting. Methods: An institutional review board–approved, retrospective review of the charts of 331 (83%) males (6 bilateral, nonsimultaneous) and 69 (17%) females diagnosed with Achilles tendon ruptures over a 10-year period was undertaken. Average age was 46.4 years with 310 (76%) ruptures diagnosed and managed acutely (less than 4 weeks), whereas 96 (24%) were chronic (more than 4 weeks since the injury). Patients were assessed for mechanism of injury and previously described underlying risk factors. Results were assessed according to age (greater or less than 55 years), body mass index (BMI), and time to diagnosis. Results: Sporting activity was responsible for 275 ruptures (68%). This was higher in patients younger than 55 years of age (77%) than those older than 55 years (42%). Basketball was the most commonly involved sport, accounting for 132 ruptures (48% of sports ruptures, 32% of all ruptures), followed by tennis in 52 ruptures (13%, 9%), and football in 32 ruptures (12%, 8%). In all, 20 ruptures were reruptures of the same Achilles tendon, of which 17 had previously been treated nonsurgically. In this study, recent quinolone use (2%) and African American race (31%) were not major risk factors for rupture as described in other studies. Older patients and patients with a BMI greater than 30 were more likely to be injured in nonsporting activities and more likely to have their diagnosis initially not recognized resulting in their presentation more than 4 weeks following the injury. Conclusion: In this study, sports participation was the most common mechanism, but not to the same extent seen in the European or US military studies. Basketball was the most commonly involved sport, as compared to soccer in Europe. Age and BMI had a directly proportional correlation with time to diagnosis. Level of Evidence: Level II, epidemiologic study.