Stuart D. Katchis

Outcomes in hallux rigidus patients treated nonoperatively: a long-term follow-up study.

The purpose of this study was to analyze radiographic outcome and patient satisfaction in non-operative care of hallux rigidus. Twenty-two patients representing 24 feet were surveyed and radiographed. Average follow-up was 14.4 years (range, 12–19 years). In 75% (18/24) of the feet, the patients would “still chose not to have surgery” if they had to make the decision again. The pain remained about the same in 22 feet, improved with time in one, and became worse in one. The most common reason given for not having surgery was that the pain was not severe enough. The most common type of self-care was a shoe with an “ample toe box.” More patients benefited from a stiff sole than a soft sole, but the majority of patients did not cite the sole of the shoe as being important. There was measurable loss of cartilage space radiographically over time in 16 of 24 feet, and in eight of the 16 feet, the loss of cartilage space was dramatic. The majority of hallux rigidus patients rated their pain as staying the same over a twelve-year period, despite significant deterioration of joint space noted radiographically. The study provides data for the hallux rigidus patient who asks, “what happens if I choose not to have surgery?”

SPECT/CT in the Management of Osteochondral Lesions of the Talus:

Background: The treatment of osteochondral lesion of the talus (OLT) is mainly based upon the stage of the disease so accurate imaging is crucial. SPECT/CT combines bone scan with high-resolution CT and can provide functional-anatomical images in a single stage. The purpose of this study was to assess the value of SPECT/CT in the management of OLT. Materials and Methods: From 2004 to 2009, 22 patients with OLT were identified that had both SPECT/CT and MRI of the foot and ankle. All charts were reviewed to ascertain the reason for ordering the SPECT/CT and the additional information obtained. AOFAS outcome scores were calculated at the time of followup. Results: Twelve patients underwent ankle arthroscopy for debridement or drilling of the osteochondral lesion. The mean AOFAS score in these 12 patients was 83.6. SPECT/CT helped preoperative planning by identifying the exact location of the active lesion, especially in multifocal disease or revision surgeries while showing the depth of the active lesion. Ten patients had conservative management due to minimal or no activity over the lesion on SPECT/CT images. The mean AOFAS score in these ten patients was 78.8 which was comparable to the operative group. Conclusion: We believe SPECT/CT was able to provide additional diagnostic value by demonstrating a co-existing pathology as a potential cause of pain and in preoperative planning by showing the depth of activity and the precise location of the active segment in multiple lesions. Level of Evidence: III, Retrospective Case Control Study

Traumatic foot and ankle injuries in the athlete

Unrecognized and inappropriately managed foot and ankle injuries can lead to significant long-term functional disability. As many of the above injuries are frequently diagnosed late or not even considered because of the benign appearance of the foot or radiograph, it behooves the sports medicine physician to carefully assess the foot and obtain appropriate radiographs, including stress views as needed. Although quick return to athletic play is among the goals of treatment for the elite athlete, this must be tempered by the fact that certain injuries require significantly greater time for complete recovery. A functional rehabilitation program is the best means to rapidly return the player to competition and while prolonging the athletic career.

Quantitative Analysis of Cancellous Bone Graft Available from the Greater Trochanter

To quantify the amount of cancellous bone graft available from the greater trochanteric region, 20 paired iliac crest-proximal femur specimens were harvested and compared in 10 adult pelvises. A 1.3 × 1.3-cm cortical window was made in the lateral aspect of the proximal femur 2 cm distal from the tip of the greater trochanter. Cancellous bone evacuation was performed by curettage. The extent of harvest was mechanically limited by the medial wall of the trochanter and by curette impingement on the margins of the cortical window. The graft was quantitated after maximal digital compression in a 10-ml syringe and compared with cancellous graft obtained from the paired anterior iliac crest. The average compressed volume of cancellous bone harvested from the greater trochanter was 6.5 ml (range, 4.2–9.6 ml). The average iliac crest cancellous bone volume was 6.0 ml (range, 2.7–8.8 ml). Differences in graft volume between the anterior iliac crest and the trochanter were not statistically significant. The resulting defect in the proximal femur remained isolated to the trochanteric region. In this study, we demonstrate that cancellous bone is available from the greater trochanteric region in an amount similar to that available from the anterior iliac crest. We also show that it is obtainable in a reproducible manner. Our clinical experience of over 100 cases has demonstrated acceptable morbidity associated with this technique. The greater trochanteric region may be used as a secondary source of autogenous cancellous bone graft when specific procedures demand more bone graft than available from the iliac crest alone, or in patients who have had previous iliac crest graft harvest.

Open Reduction Internal Fixation of Posterior Malleolus Fractures via a Posteromedial Approach

Category: Ankle, Trauma Introduction/Purpose: Ankle fractures with a posterior malleolus component are complex injuries to manage. Due to the heterogeneous morphology of these fractures and lack of high-quality evidence, methods of surgical fixation are controversial and highly variable. The most commonly used surgical methods include indirect reduction via a percutaneous anterior approach or direct reduction via a posterolateral approach. For large posterior malleolus fractures with medial extension, direct reduction via a posteromedial approach is an alternative surgical option. The purpose of this study was to report on a large series of posterior malleolus fractures treated via a novel posteromedial approach. The study hypothesized that fixation of large posterior malleolus fractures with medial extension via a posteromedial approach results in anatomic reduction and stable plate fixation. Methods: From 2008 to 2015, 23 of 244 (9.4%) consecutive operative ankle fractures were identified as posterior malleolus fractures treated using a posteromedial approach (Figure 1). All patients had pre-operative computed tomography scans to confirm the presence of a posterior malleolus fracture with medial extension (Figure 2-4). A posteromedial incision was made and fracture was reduced with the saphenous vein retracted anteriorly and the posterior tibial tendon retracted posteriorly. Patient charts were retrospectively reviewed for demographics, injury history, surgical details, follow-up time, and any post-operative complications. Post-operative radiographs were reviewed to ensure that anatomic reduction and stable fixation was maintained (Figure 5). Results: 73.9% (17/23) of the patients were female and the average age at the time of surgery was 54.6 years (range, 26-86 years). There were no open fractures, but 8/23 (34.7%) patients required external fixation prior to open reduction internal fixation (ORIF) for soft tissue management. The average follow-up time was 11.0 months (range, 0.3 to 41.4 months). All patients healed completely on a clinical and radiographic basis. Anatomic reduction and stable plate fixation was obtained intra-operatively in all patients and maintained at maximal follow-up. Eight (34.7%) patients underwent removal of hardware. There was a 13.0% (3/23) post-operative complication rate: 1 patient had cellulitis, 1 patient had osteomyelitis involving the fibula, and 1 patient had symptomatic heterotopic ossification. All complications resolved with appropriate management. Conclusion: ORIF of posterior malleolus fractures via a posteromedial approach achieved anatomic reduction, stable plate fixation, and complete healing in all patients. Posteromedial approach enables direct visualization and anatomic reduction of large posterior malleolus fractures. Fixation of the posteromedial tibial plafond is important because, unlike the posterolateral aspect, there are no ligamentous insertions that can provisionally reduce the fracture fragment by ligamentotaxis. In concurrence with previous literature, our study demonstrates that posteromedial approach is a reasonable alternative to other more commonly used methods for treating these fractures.