Umur Aydogan

Extensor retinaculum augmentation reinforces anterior talofibular ligament repair.

Repair of the anterior talofibular ligament often is augmented with the inferior extensor retinaculum because it is thought to reinforce the primary ligament repair. The additional dissection and suturing extend the duration of surgery, and not all surgeons routinely include inferior extensor retinaculum augmentation in anterior talofibular ligament repairs. To determine whether there is a reasonable basis for this surgery, we ascertained the degree to which inferior extensor retinaculum augmentation reinforced the primary anterior talofibular ligament repair. Matched pairs of cadaveric ankles had controlled inversion while monitoring resistance to inversion, first with the anterior talofibular ligament sectioned, then with primary anterior talofibular ligament repair alone or with inferior extensor retinaculum augmentation. The resistance to ankle inversion was greater at 5°, 10°, 15°, 20°, and 25° rotation in ankles that had inferior extensor retinaculum augmentation. Anterior talofibular ligament failure occurred at similar inversion angles in both treatment groups, but the primary anterior talofibular ligament repair required more torque to fail in the augmented group. With these ankle loading conditions, inferior extensor retinaculum augmentation provided protection to the primary anterior talofibular ligament repair, indicating that broader clinical use of augmentation may be warranted.

The functional outcome of displaced intra-articular calcaneal fractures: a comparison between isolated cases and polytrauma patients.

This study was conducted to analyze the functional outcome of displaced intra-articular calcaneal fractures in polytrauma patients and isolated cases, and to make a comparison between them. Twenty-eight patients (12 women and 16 men) with an average age of 37 (range, 13 to 60) who had 35 displaced intra-articular calcaneal fractures were included in this study. Among these, 17 fractures were due to polytrauma and 18 were due to isolated trauma. According to Sanders CT classification, 19 fractures (54.3%) were classified as type II, 10 fractures (28.5%) as type III and six fractures (17.2%) as type IV. The treatment consisted of operative and closed methods. The average follow-up time was 38 months (range, 18 to 83 months). The functional outcome was evaluated using Maryland Foot Score and there were three (17%) excellent, nine (52.9%) good and five (29.5%) fair results in polytrauma patients Seven (38.8%) excellent, 10 (55.6%) good and one (5.6%) fair results were seen in isolated cases. When compared with isolated cases, the functional outcome of displaced intra-articular calcaneal fractures in polytrauma patients was worse. With the findings available, it appears that foot trauma is usually ignored and should be treated without delay as for other system injuries in polytrauma patients.

Ankle Arthritis: Review of Diagnosis and Operative Management

The diagnostic and therapeutic options for ankle arthritis are reviewed. The current standard of care for nonoperative options include the use of nonsteroidal antiinflammatory drugs, corticosteroid injections, orthotics, and ankle braces. Other modalities lack high-quality research studies to delineate their appropriateness and effectiveness. The gold standard for operative intervention in end-stage degenerative arthritis remains arthrodesis, but evidence for the superiority in functional outcomes of total ankle arthroplasty is increasing. The next few years will enable more informed decisions and, with more prospective high-quality studies, the most appropriate patient population for total ankle arthroplasty can be identified.

Repair of Chronic Tibialis Anterior Tendon Rupture With a Major Defect Using Gracilis Allograft

Background: Tibialis anterior tendon (TAT) rupture is an uncommon injury, however, it can cause substantial deficit. Diagnosis is often delayed due to lack of initial symptoms; yet loss of function over time typically causes the patient to present for treatment. This delay usually ends up with major defects creating a great technical challenge for the operating surgeon. We present a novel technique and operative algorithm for the management of chronic TAT ruptures with a major gap after a delayed diagnosis not otherwise correctable with currently described techniques in the literature. This technique has been performed in 4 cases without any complications with fairly successful functional outcomes. Methods: For the reconstruction of chronic TAT rupture with an average delay of nine weeks after initial injury and gap of greater than 10 cm, a thorough operative algorithm was implemented in 4 patients using a double bundle gracilis allograft. Patients were then kept nonweightbearing for 6 weeks followed by weightbearing as tolerated. They began physical therapy with a focus on ankle exercises and gradual return to normal activity at 8 weeks, with resistance training exercises allowed at 12 weeks. Results: At a mean follow-up time of 24.5 months, all patients reported significant pain relief with normal gait pattern. There were no reported intra- or postoperative complications. The average Foot and Ankle Ability Measure score increased to 90 from 27.5 in the postoperative period. All patients were able to return their previous activity levels. Conclusions: Gracilis allograft reconstruction as used in this study is a viable and reproducible alternative to primary repair with postoperative results being favorable without using complex tendon transfer techniques or autograft use necessitating the functional sacrifice of transferred or excised tendon. To the best of our knowledge, this is the first study demonstrating a successful technique and operative algorithm of gracilis allograft reconstruction of the TAT with a substantial deficit of greater than 10 cm with favorable results. Levels of Evidence: Level IV: Operative algorithm with case series

Comparison of Proximal and Distal Oblique Second Metatarsal Osteotomies with Varying Achilles Tendon Tension: Biomechanical Study in a Cadaver Model.

BACKGROUND The optimal surgery for reducing pressure under the second metatarsal head to treat metatarsalgia is unknown. We tested our hypothesis that a proximal oblique dorsiflexion osteotomy of the second metatarsal would decrease second-metatarsal plantar pressures in a cadaver model with varying Achilles tendon tension. We also tested the plantar pressure effects of two popular techniques of distal oblique osteotomy. METHODS Twelve fresh-frozen feet from six cadavers were randomly assigned to either the distal osteotomy group (a classic distal oblique osteotomy followed by a modified distal oblique osteotomy) or proximal metatarsal osteotomy group. Each specimen was tested intact and then after the osteotomy or osteotomies. The feet were loaded with 0, 300, and 600 N of Achilles tendon tension and a 400-N ground reaction force. Plantar pressures were measured by a pressure sensitive mat and analyzed in sections located under each metatarsal. RESULTS The proximal metatarsal osteotomy significantly reduced average pressures beneath the second metatarsal head during both 300 and 600 N of Achilles tendon loading by an average of 19.4 and 29.7 kPa, respectively (p < 0.05). The modified distal oblique osteotomy significantly decreased these pressures during 600 N of Achilles tendon loading, by a mean of 20.2 kPa, which was to a lesser extent than the proximal metatarsal osteotomy. Interestingly, the classic distal oblique osteotomy was not found to have significant effects on pressures beneath the second metatarsal head. CONCLUSIONS The proximal oblique dorsiflexion metatarsal osteotomy may be the most effective procedure for decreasing plantar pressures under the second metatarsal. The modified distal oblique osteotomy may be the second most effective. CLINICAL RELEVANCE The findings of this biomechanical study help shed light on which of the common second metatarsal osteotomies are best for decreasing plantar pressures.

Algorithm for Severe Hallux Valgus Associated With Metatarsus Adductus

Background: Radiographic angles, such as the intermetatarsal angle, hallux valgus angle, and distal metatarsal articular angle, are commonly used to help guide operative planning for soft tissue and osseous treatment options for hallux valgus. Hallux valgus treatment in the setting of associated metatarsus adductus is less common and not well described. The presence of metatarsus adductus reduces the gap between the first and second metatarsals. Consequently, it complicates the measurement of the first-second intermetatarsal angle and can limit the area available for transposition of the first metatarsal head. A compensatory pronation is also created, which must be compensated for. We present 4 cases of patients that had hallux valgus with severe metatarsus adductus treated operatively, as well as a treatment algorithm. Methods: For concomitant correction of both the metatarsus adductus and the hallux valgus, a thorough surgical treatment algorithm was implemented to address the hallux, lesser toe deformities, and pes planus deformity. Postoperatively, the patients were kept non–weight bearing for 6 weeks, followed by gradual weight bearing in a protective boot. Physical therapy was instituted at the start of weight bearing to encourage a return to activities of daily living. Results: At follow-up, patients reported significant relief of their pain symptoms with a narrower and improved appearance of the foot. No recurrence was noted. One patient used a medial arch support but was otherwise symptom free. Radiographic measurements improved on postoperative radiographs. Conclusions: For the treatment of hallux valgus with metatarsus adductus, the second and third metatarsals may need to be addressed for the first metatarsal to be laterally transposed adequately. Overall, this comprehensive approach addresses the hindfoot, midfoot, and forefoot for patients with hallux valgus associated with metatarsus adductus, with successful results. Level of Evidence: Level V, case series.

Giant cell tumor of the distal phalanx of the great toe: a case report.

Giant cell tumors are rarely seen in the foot. They can cause a significant amount of pain and deformity due to their aggressive and recurrent nature. We present the unusual case of a giant cell tumor of the distal phalanx of the hallux in a 39-year-old man. Levels of Evidence: Therapeutic Level IV, Case Report

Avoiding Pitfalls of Tibiotalocalcaneal Nail Malposition With Internal Rotation Axial Heel View

Background. Tibiotalocalcaneal (TTC) nails are often used for complex hind foot arthrodesis and deformity correction. The natural valgus alignment of the hindfoot creates a challenge to optimum placement of the guidewire and eventual nail with a straight or valgus-curved nail. Methods. Five fresh frozen cadavers were used for placement of a TTC guidewire with standard anterior-posterior (AP), lateral, and Harris axial heel views as a reference for proper placement. The limb was then rotated 15°, 30°, and 45° both internally and externally to evaluate the perceived amount of osseous purchase within the calcaneus. The TTC nail was then inserted and dissection was performed to demonstrate proximity of the nail to the sustentaculum tali and neurovascular structures. Results. A 30° internal rotation Harris axial heel view demonstrated the most accurate representation of osseous purchase within the calcaneus with the guidewire and nail placement. When the guidewire was placed with standard imaging the nail was often ultimately placed in close proximity to the sustentaculum tali and neurovascular structures. Conclusion. Careful placement of the guidewire prior to reaming and nail placement should be undertaken to avoid neurovascular injury and to increase osseous purchase. For optimal guidewire placement, the authors suggest using appropriate anatomic landmarks and using a 30° internally rotated Harris axial heel view to verify correct placement. Levels of Evidence: Level V: Expert opinion

Prognostic Risk Factors for Complications Associated with Below the Knee Amputations

Category: Other Introduction/Purpose: Below the knee amputation (BKA) is an effective surgical procedure for individuals with severe injury or infection to their lower extremities. However, patients who receive these procedures are subject to significant morbidity and a high rate of postoperative complications due to the presence of multiple concomitant comorbidities. Despite the wide practice of this intervention, prognostic risk factors aiding in predicting surgical outcomes in these patients are poorly understood. The purpose of this study is to evaluate risk factors that may contribute to the outcomes of BKA procedures. Methods: The clinical and radiographic outcomes for 89 patients ages 19-90 who underwent BKA were retrospectively evaluated from 2012-2017. Postoperative complications of mortality, infection, and reoperation were evaluated with patient and surgical variables. Patient variables included: age, ambulatory status, obesity, diabetes, HbA1C2 levels, neuropathy, smoking, Charlson Comorbidity Index (CCI), and American Society of Anesthesiologists (ASA) classification. Surgical variables evaluated included: presence of pre-op infection, pre-op ambulatory status, tourniquet time, tourniquet pressure, and usage of prophylactic antibiotics. Results: Of the patients evaluated there was an overall complication rate of 49% (44/89) and a mortality rate of 19% (17/89). Patients with diabetes (p=.035), a greater score on the Charlson Comorbidity Index (p=.001), and an ASA classification =3 (p=.005) were associated with a greater risk of mortality. Operative values (i.e. tourniquet time, tourniquet pressure etc.) did not affect patient mortality rates in a significant way, but there was a higher incidence of complications (i.e. mortality, post-op infections, and reoperations) with patients with pre-operative infections. Conclusion: Diabetes, a higher CCI score and a greater ASA value were found to be significant predictors of patient mortality after BKA (p<0.05). Future perioperative optimization in these patients identified as high risk may improve patient outcomes in the future.

Treatment trends for acquired hallux valgus among orthopedic surgeons and podiatrists

Category: Bunion Introduction/Purpose: Foot and ankle surgery is unique in that both orthopedic surgeons and podiatrists perform many of the same procedures. Very little data exists comparing the two groups for treatment trends and potential complications for acquired hallux valgus deformity. The Truven Health MarketScan® Commercial Claims and Encounters database offers a breadth of information for comparing commercially available health insurance claims. The MarketScan® database was utilized to gain understanding in treatment trends between podiatrists and orthopedic surgeons. Methods: MarketScan® database was used to retrospectively search from 2005-2014 for cases involving a diagnosis of hallux valgus (ICD-9 735.0) that included procedural codes for distal metatarsal osteotomy (CPT 28296), double osteotomy (CPT 28299), and first tarsometatarsal arthrodesis (CPT 28297). The procedures were then divided into the provider groups of podiatry (PO) or orthopedic surgery (OS) to compare the trends in treatment options. Additionally, hospital admission within 3 months, reoperation, and pain medication prescriptions were tracked for the separate groups and for the individual procedures within those groups. Results: From 2005-2014, 206409 patients were identified for comparison. Podiatrists performed 87.5% of hallux valgus corrective procedures with significantly different (p<0.0001) treatment approaches with 78.9% distal metatarsal osteotomy (OS 63.2%), 16.2% double osteotomy (OS 25.3%), and 4.9% first tarsometatarsal arthrodesis (OS 11.5%). Orthopedic surgeons and podiatrists demonstrated similar hospital admission rates 3 months from surgery or reoperation at 1.8% and 1.5% respectively. Amongst all providers, there was significantly more (p<0.001) reoperations and admissions after first tarsometatarsal arthrodesis (2.1%) when compared with distal metatarsal (1.5%) and double (1.6%) osteotomies. 9254 patients were available for prescription drug comparison that demonstrated significantly different prescribing trends with orthopedic surgeons prescribing hydrocodone 2.8% (PO 12.9%), oxycodone 39.4% (PO 10.8%), and tramadol 43.4% (PO 60.0%). Conclusion: A large portion of hallux valgus correction is being performed by podiatrists amongst privately insured patients. Podiatrists were much more likely to perform distal metatarsal osteotomy while orthopedic surgeons were more likely to perform double osteotomies and first tarsometatarsal arthrodesis. Hospital admission within 3 months was similar for the providers. Podiatrists were more likely to prescribe hydrocodone and tramadol while orthopedic surgeons demonstrated greater numbers with oxycodone prescriptions.