Terrence M. Philbin

Treatment of Syndesmotic Disruptions with the Arthrex Tightrope™: A Report of 25 Cases

Background: The complexity of syndesmotic injuries, often with both bone and soft tissue injury mandates an expeditious diagnosis and treatment to avoid unfavorable long term outcomes. Various methods of fixation of the syndesmosis have been reported. We present the largest series evaluating the Arthrex Tightrope™ for management of syndesmotic injuries. Materials and Methods: Twenty-five patients with disruption of the distal tibiofibular articulation underwent treatment with an Arthrex Tightrope™. In 21 cases, a single tightrope was placed, and in four cases, two tightropes were utilized. Associated ankle fractures were treated using proper AO technique. Those patients with diabetes and/or neuroarthropathic changes foot or ankle were not included in this study. Postoperative evaluation parameters included radiographic measurements, a modified AOFAS scoring system and SF-12. Results: Average followup was 10.8 months. The mean time to full weight-bearing was 5.5 (range, 2 to 8) weeks. Postoperative radiographic analysis of the mean distance from the tibial plafond to the placement of the tightrope(s), medial clear space, average postoperative tibiofibular overlap and the mean tibiofibular clear space demonstrated no evidence of re-displacement of the syndesmotic complex at an average of 10.8 (range, 6 to 12) months. The modified AOFAS hindfoot scoring scale and SF-12 both demonstrated significant improvements; preoperative values were assessed in the office with the first patient visit as they are incorporated into the patient intake form that each patient fills out at the initial visit. Conclusion: Utilization of the tightrope in diastasis of the syndesmosis should be considered as a good option. The method of placement is quick, can be minimally invasive, and obviates the need for hardware removal. In this series, it maintained excellent reduction of the syndesmosis.

Transosseous Fixation of the Distal Tibiofibular Syndesmosis: Comparison of an Interosseous Suture and Endobutton to Traditional Screw Fixation in 50 Cases

UNLABELLED In this prospective cohort study, we compared screw fixation to interosseous suture with endobutton repair of the syndesmosis. Outcomes of interest included preoperative and postoperative modified American Orthopedic Foot and Ankle Society (AOFAS) hindfoot and ankle scores, and Short Form-12 health status scores, as well as radiographic measurements and the time to full weight bearing. Mean averages and ranges were calculated for numeric variables, and outcomes for each fixation group were compared statistically with Student t test. The cohort consisted of 50 patients; 25 in the screw fixation group and 25 in the interosseous wire with endobuttons group. The mean patient age was 34.68 (15 to 55) years in the interosseous suture endobutton group and 36.68 (17 to 74) years in the screw group, and the mean follow-up was 10.78 (range 6 to 12) months in the interosseous suture endobutton group, and 8.20 (range 4 to 24) months in the screw group. No statistically significant differences (P < or = .05) were noted in regard to age, follow-up duration, time to postoperative weight bearing, or subjective outcome scores between the fixation groups; although statistically significant improvements were noted in the subjective scores for each fixation group between the preoperative and postoperative measurements. The results of this study indicate that the interosseous suture with endobuttons is a reasonable option for repair of ankle syndesmotic injuries, and may be as effective as traditional internal screw fixation. LEVEL OF CLINICAL EVIDENCE 2.

Interpositional Arthroplasty of the First MTP Joint Using a Regenerative Tissue Matrix for the Treatment of Advanced Hallux Rigidus

Background: Treatment options are limited for young and active patients with hallux rigidus of the first metatarsophalangeal (MTP) joint. Soft-tissue interpositional arthroplasty is a promising alternative. Methods: The surgical technique for interpositional arthroplasty utilizing a human acellular dermal regenerative tissue matrix as a spacer is described. A retrospective review of a consecutive series of the first nine patients with Coughlin grade 3 halux rigidus who underwent this procedure is presented. Five patients were female and four were male, with a mean age of 53.3 years, a mean body mass index of 28.6, and a mean duration of symptoms of 3.1 years. Results: The mean length of followup was 12.7 months, with no reported complications or failures. The mean total AOFAS score and pain sub-score were significantly higher at the most recent followup (87.9 and 34.4, respectively) versus preoperatively (63.9 and 17.8, respectively). Conclusions: These excellent early results and lack of complications may be due to the minimal bone resection associated with the procedure. This technique does not require autograft harvesting, is bone-sparing by preserving the plantar plate, and maintains the natural intrinsics of the joint by preserving its associated tendons and the FHB insertion. The sesamoid articulation also is resurfaced. Although further followup is needed, this technique may offer the young and active patient with advanced hallux rigidus an opportunity to maintain an active lifestyle, while retaining the possibility for more surgical options should the condition progress.

Osteochondral Lesions of the Talus: Predictors of Clinical Outcome:

Background: Osteochondral lesions of the talus (OLT) are a common and challenging condition treated by the orthopedic foot and ankle surgeon. Multiple operative treatment modalities have been recommended, and there are several factors that need to be considered when devising a treatment plan. In this study, we retrospectively reviewed a group of patients treated operatively for osteochondral lesions of the talus to determine factors that may have affected outcome. Methods: A retrospective chart review of clinical, radiographic and operative records was performed for all patients treated for OLTs via marrow stimulation technique. All had a minimum followup of 6 months or until return to full activity, preoperative magnetic resonance imaging (MRI) of the OLT to determine size, and failure of nonoperative treatment. Results: A total of 130 patients were included in the study. This included 64 males and 66 females. The average patient age at the time of surgery was 35.1 ± 13.7 (range, 12 to 73) years. The average followup was 37.2 ± 40.2 (range, 7.43 to 247) weeks. The average size of the lesion was 0.84 ± 0.67 cm2. There were 20 lesions larger than 1.5 cm2 and 110 lesions smaller than 1.5 cm2. There were 113 contained lesions and 17 uncontained lesions. OLTs larger than 1.5 cm2 and uncontained lesions were associated with a poor clinical outcome. Conclusions: The treatment of osteochondral lesions of the talus remains a challenge to the foot and ankle surgeon. Arthroscopic debridement and drilling will often provide satisfactory results. However, larger lesions and uncontained lesions are often associated with inferior functional outcomes and may require a more extensive initial procedure. Level of Evidence: IV, Retrospective Case Series

The Peroneal Tubercle: Description, Classification, and Relevance to Peroneus Longus Tendon Pathology

Background: The size and configuration of the peroneal tubercle has been implicated in the pathogenesis of peroneal tendon tears and tenosynovitis. The purpose of this study was to determine the size and prevalence of the peroneal tubercle and devise a classification scheme according to the structure of the tubercle. Methods: One hundred and seventeen calcanei were selected from 59 human skeletons in an osteological collection (one calcaneus was missing). Three were excluded because of the poor condition, leaving 114 calcanei. The peroneal tubercle was measured in length, height, and depth and its structure subjectively described as flat, prominent, concave, or tunnel for each specimen when present. Results: This study revealed a peroneal tubercle prevalence of 90.4% (103) in 114 calcanei. The average length, height, and depth of the tubercle were 13.04 mm (range 3.61 mm to 26.66 mm), 9.44 mm (range 3.67 mm to 23.40 mm), and 3.13 mm (range 1 to 10), respectively. The peroneal tubercle was classified structurally as flat in 44 (42.7%), prominent in 30 (29.1%), concave in 28 (27.2%), and tunnel in one (1.0%). Conclusion: This data may further help to understand the size and assorted configurations of the peroneal tubercle and how they relate to peroneus longus tendon pathology.

Retrograde Intramedullary Nail Arthrodesis for Avascular Necrosis of the Talus

Background: Avascular necrosis (AVN) of the talus from any etiology is a devastating pathology. There are few salvage options available and controversy exists as to the surgical management for patients with talar AVN. The authors present their results of tibiotalocalcaneal arthrodesis with a retrograde nail. Materials and Methods: A comprehensive chart and radiographic review was pulled from our database for patients with AVN of the talus, who were treated by tibiotalocalcaneal fusion with retrograde intramedullary nail. Primary outcome was union, with time to clinical union as a secondary endpoint. Results: Fourteen patients were included. The average age at surgery was 47.4 ± 12.8 years, there were nine female patients, and the average Body Mass Index was 33.5 ± 6.0. Surgical risk factors included two patients who smoked, one was diabetic, and one had a preoperative ulceration. The average time to partial weightbearing was 70.6 ± 25.4 days, and the average time to full weightbearing was 100.6 ± 35.5 days. Four patients had postoperative complications, while no patients required major revision surgery. Twelve patients went on to solid fusion, while two went on to a stable, braceable pseudoarthrosis. Eight patients were able to return to shoes, and eight were able to walk unaided at final followup. Conclusion: Salvage of talar AVN is possible by tibiotalocalcaneal arthrodesis with an intramedullary nail. Physicians may offer this as a salvage option to patients with a high likelihood of successful fusion. Level of Evidence: IV, Retrospective Case Series

Arthroscopic treatment of osteochondral lesions of the tibial plafond.

Background: Osteochondral lesions of the distal tibial plafond (OLTPs) are an uncommon problem. The purpose of this study was to evaluate clinical outcomes following arthroscopic treatment of OLTPs. Methods: Retrospective chart review was performed on all patients treated arthroscopically for OLTPs. Treatment consisted of generalized synovectomy followed by curettage of the lesion and microfracture. If a cartilage cap was intact, antegrade drilling was performed. Cystic defects were treated with curettage of the cyst and filling of any defect with bone graft. Results: A total of 13 patients were included. Nine patients had isolated lesions, while four had lesions of the distal tibial plafond and talar dome. Average followup was 156 (range, 38 to 402 ± 117.9) weeks and average patient age was 32.9 (range, 14 to 50 ± 11.8) years. Eleven of 13 patients were available for followup modified AOFAS score. The average preoperative score was 35.2 (range, 24 to 49 ± 7.1). The average postoperative modified AOFAS score was 50.4 (range, 33 to 56 ± 7.6). There were four patients (30.8%) with a poor outcome. Conclusion: OLTPs can be challenging to treat. Arthroscopic treatment can lead to improved outcomes. However, the higher incidence of poor outcomes in our series may indicate less predictability in the treatment of OLTPs and that outcomes may not be equivalent to previous reported studies on OLTPs or osteochondral lesions of the talus. Level of Evidence: IV, Retrospective Case Series

A Soft-Tissue Interpositional Arthroplasty Technique of the First Metatarsophalangeal Joint for the Treatment of Advanced Hallux Rigidus Using a Human Acellular Dermal Regenerative Tissue Matrix

Treatment options for young and active patients with advanced hallux rigidus of the first metatarsophalangeal joint are limited. Soft-tissue interpositional arthroplasty is a promising alternative. A minimally invasive interpositional arthroplasty technique using a human acellular regenerative tissue matrix is described. The preliminary results of a consecutive series of the first 8 patients with Coughlin grade 3 classifications who underwent this procedure are presented. Five patients were women and 3 were men, with a mean age of 50.2 years and a mean body mass index of 27.6. The mean length of follow-up was 10.1 months, with no reported failures. No complications, such as infection, inflammatory reactions, push-off strength loss, malalignment, or instability occurred. The mean total American Orthopaedic Foot and Ankle Society score and pain subscore were significantly higher at the most recent follow-up (89.6 and 35, respectively) versus preoperatively (66.7 and 20, respectively). The improvement in Coughlin classification to a mean grade of 1.6 was also statistically significant. These excellent early results and lack of complications may be because of the minimally invasive nature of the procedure. This technique does not require autograft harvesting, is bone-sparing, and maintains the natural intrinsics of the joint by preserving its associated tendons and the flexor hallucis and brevis insertion. The sesamoid articulation also is resurfaced, which may further extend the survivorship of the procedure. Although further follow-up is needed, the use of this minimally invasive technique as the first surgical intervention for the treatment of advanced hallux rigidus may offer the young and active patient an opportunity to maintain an active lifestyle while reserving the possibility for more aggressive surgical options should the condition progress.

Retrograde Drilling of Osteochondral Lesions of the Talus

This study evaluates the use of retrograde drilling in medial osteochondral lesions of the talus (OLTs) with intact articular surfaces. During a 2-year period, 8 consecutive patients underwent surgical treatment for symptomatic posterior medial OLT. All patients underwent arthroscopy of the ankle followed by retrograde drilling of the talar lesion. A novel cannulated system was used to target the lesion, remove the necrotic segment, and then backfill using Grafton gel. The average age of the patients was 36 years old (range, 12-49 years). Follow-up ranged from 8 to 44 months (mean 24 months). One patient was lost to follow-up. Of the remaining 7, outcomes were assessed with a modified American Orthopaedic Foot and Ankle Society (AOFAS) ankle/ hindfoot scale and the SF-12 general health survey. Four patients had repeat magnetic resonance imaging scans at 1-year follow-up. The preoperative AOFAS scores from the modified hindfoot scale ranged from 0 to 41 (mean 22). Postoperative scores ranged from 52 to 68 (mean 56), with a mean improvement of 34 points. The SF-12 has 2 components: the physical component score (PCS) and the mental component score (MCS). Mean preoperative and latest follow-up SF-12 PCS scores were 35.8 and 44.0, respectively. Mean preoperative and latest follow-up SF-12 MCS scores were 40.7 and 52.8, respectively. In this limited series, this technique appears to give comparable short-term results to previously described techniques. Use of a cannulated system simplifies the surgical procedure. Overall, this procedure offers decreased operative time and maximizes safety and accuracy with retrograde talar drilling.

Lateral Column Lengthening Using Allograft Interposition and Cervical Plate Fixation

Lateral column lengthening has been used successfully in the treatment of stage II adult-acquired pes planovalgus deformity. The purpose of this study is to review the union rate when allograft material is used and the osteotomy stabilized with a cervical plate. A retrospective review was performed on 28 feet in 26 patients who underwent correction of stage II pes planovalgus deformity using a lateral column lengthening with allograft tricortical iliac crest stabilized with a cervical plate. Patients were evaluated preoperatively and postoperatively using a modified American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale and the Short Form–12 health survey, as well as radiographically by assessing the talonavicular coverage angle. At a mean follow-up of 9 months, the mean total modified AOFAS score and pain subscore were significantly higher (45.6 and 25.0, respectively) versus preoperatively (27.3 and 11.2, respectively). Graft incorporation occurred in all but one case, and the average length of time to union was 10.06 weeks. Complications included 4 hardware removals, 1 nonunion, 1 graft penetration of the calcaneocuboid joint, and 2 cases of calcaneocuboid joint arthritis. Lateral column lengthening using allograft tricortical iliac crest bone graft with cervical plate fixation is a viable option for the correction of acquired pes planovalgus deformity. Allograft bone avoids donor site morbidity of autogenous iliac crest grafts and was not shown to increase rates of nonunion. Cervical plate fixation avoids the necessity of penetrating the graft with a screw and is associated with high patient satisfaction and radiographic union