W. Bret Smith

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

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

Opening Wedge Osteotomies for Correction of Hallux Valgus A Review of Wedge Plate Fixation

Osteotomy of the proximal metatarsal for the correction of moderate to severe hallux valgus deformity is commonly performed. The purpose of this study is to review the early results of a technique for the correction of hallux valgus, an opening wedge osteotomy of the proximal first metatarsal with opening wedge plate fixation. A review was performed of the results of 47 patients (49 feet) who underwent correction of hallux valgus with proximal metatarsal opening wedge osteotomy. All osteotomies were secured with plate fixation on the medial side. Evaluation consisted of preoperative and postoperative radiographic as well as clinical evaluations. Mean corrections of 7° were achieved for the 1-2 intermetatarsal angles. Fourteen complications occurred, 6 of which involved mild hardware irritation and did not affect outcome. Four nonunions or delayed unions were identified. The authors find the opening wedge osteotomy of the proximal first metatarsal to be a technically straightforward procedure for correcting moderate to severe hallux valgus. The correction obtained is comparable to other described techniques.

Single-Screw Fixation for Subtalar Joint Fusion Does Not Increase Nonunion Rate

A philosophical shift toward more joint-sparing procedures has led to increased use of isolated subtalar joint (STJ) versus triple arthrodesis. Union rates for STJ fusion range from 47% to 100%, leading to controversy regarding the optimal type, orientation, and amount of internal fixation. The purpose of this study was to determine if single-screw fixation is a predisposing factor to nonunion. Single-screw fixation is parallel to the STJ axis and may result in motion. It is hypothesized that higher nonunion rates will be observed in single-screw versus 2-screw fusions. Isolated STJ arthrodeses performed in 113 patients were retrospectively reviewed. Single screws were used in 89 (78.8%) fusions; 2 screws were used in 24 (21.2%) fusions. The mean follow-up was 11 months (range, 9-17 months). Nonunion occurred in 13 (14.6%) single-screw and 6 (25.0%) 2-screw fusions. Twenty (22.5%) single-screw and 3 (12.5%) 2-screw fusions required hardware removal. Revision surgery was performed in 6 (6.7%) single-screw and 3 (12.5%) 2-screw fusions. No significant differences in demographics were calculated between single and 2-screw fusions. Furthermore, no significant differences were observed in nonunion rate, postoperative complication incidence, or subsequent surgeries. The results from this study do not support the contention that single-screw fixation predisposes STJ fusions to nonunion. Comparable nonunion and complication incidences were observed between single and 2-screw fusions. These data suggest that the motion occurring from single-screw fixation may not be significant enough to directly affect the rate of union.

A Proposed Treatment Algorithm for Midfoot Charcot Arthropathy

Charcot arthropathy (CA) is an insidious, destructive, and disabling pathology of the foot and ankle. Efficient and effective treatment is therefore required to improve clinical outcomes and to reduce overall mortality risk. The purpose of this case series report is to propose a treatment algorithm for correcting deformity and restoring a plantigrade, shoeable foot in patients with midfoot CA. While there is no clear evidence in the literature favoring either internal or external fixation methods, it may be appropriate to use both techniques during most deformity correction cases. Depending on the presence of ulceration, single-stage and multi-stage reconstruction with either biplanar or aggressive resection can effectively address the presentation of nonviable tissue and a wide degree of variable deformity. Following midfoot reduction, medial column plating and circular external frame can be used together to effectively stabilize and protect the correction and construct. In all cases, the aim is to immediately place the patient into a Charcot Restraint Orthotic Walker boot, with the ultimate goal of transitioning to diabetic shoeing as quickly as possible.

Understanding the postoperative course and rehabilitation protocol for total ankle arthroplasty.

Total ankle arthroplasty has been a topic that has been gaining in popularity as current-generation prostheses allow for surgeons to reproduce anatomic alignment and ultimately improve outcomes. As in all types of total joint replacement, the postoperative course and treatment regime can be as important, if not more important, than the surgery itself. This often-neglected topic is discussed in this issue’s roundtable discussion by a group of surgeons whom I consider to be authorities in both ankle arthroplasty as well as its postoperative course. We have also been fortunate to get the thoughts from a physical therapist who is treating total ankle patients in his clinic on a weekly basis. As surgeons we must remember that what we do outside of the operating room can have a tremendous impact on the outcomes of our patients. I trust you will enjoy this section as much as I have, learning about the different approaches from world-class surgeons in North America. Let us start with the immediate postoperative care of ankle replacements. How are each of you managing your incisions? What type of closure? How are you dressing your total ankles postoperatively? And are you using drains or negative pressure?

What a Summer

SUMMER 2018 Undergraduate Tuition & Fees Credits In State & Out of State Tuition Student Service Fee In State & Out of State Tuition Fees 1

Understanding the basics of posterior tibial tendon dysfunction and the associated flatfoot: conservative and surgical thoughts.

337.93

Advanced Hallux Rigidus Do We Have a Choice Other Than Arthrodesis

35.71

Treatment of Fifth Metatarsal Fractures in Adults.

373.64 2