Nonunion Rate of First Metatarsal-Phalangeal Joint Arthrodesis for End-stage Hallux Rigidus with Crossed Titanium Flexible Intramedullary Nails and Dorsal Static Staple with Immediate Weight-bearing

Authors: Thomas Roukis DPM, Tristan Meusnier MD, Marc Augoyard MD

Journal:  JFAS

Abstract:  Myriad forms of fixation have been proposed for arthrodesis of the first metatarsal-phalangeal joint (MTPJ). Regardless of the fixation type, nonunion of the arthrodesis site has been purported to be a common complication. We performed a retrospective review of all patients undergoing arthrodesis of the first MTPJ for end-stage hallux rigidus with 2 crossed flexible titanium intramedullary nails and a dorsal static 10-mm titanium staple followed by immediate protected weight-bearing. The inclusion criteria were as follows: the exact internal fixation technique described was employed for end-stage hallux rigidus of the first MTPJ only; preoperative and at least 6 weeks of postoperative weight-bearing radiographs were available; weight-bearing was initiated on the operative foot immediately in a protective shoe; the patient was followed for at least 6 months postoperatively; any complication was documented; and bilateral surgery was not done in the same setting. A total of 42 female patients (51 feet) with a mean age ± SD of 69.4 ± 9.2 years met the inclusion criteria. Complications resulting from technical error during insertion of the crossed titanium flexible intramedullary nails occurred in 3 feet (5.9%), but none led to nonunion or revision surgery. One delayed union (2%) occurred but it ultimately united. The incidence of nonunion after arthrodesis of the first MTPJ consisting of 2 crossed flexible titanium intramedullary nails and a dorsal static 10-mm titanium staple for end-stage hallux rigidus in an exclusively female population was lower than the historic mean for most other fixation techniques. However, methodologically sound prospective cohort studies that focus on the use of isolated arthrodesis of the first MTPJ for end-stage hallux rigidus in both male and female patients are still needed, as are comparisons of the presented technique with other modern osteosynthesis techniques.

Keywords: degenerative joint disease, dorsal bunion, foot deformity, osteoarthritis, surgery

The Management of the Neglected Congenital Foot Deformity in the Older Child With the Taylor Spatial Frame

Authors: Atef Hassan, BS MBs MSc (Ortho) and Merv Letts, MD

Journal:  Journal of Pediatric Orthopaedics

Abstract: 

Background: Neglected or inadequately treated rigid congenitally deformed feet in older children are a nightmarish challenge for the child, the parents, and the orthopaedic surgeon. Because of the multiplicity of spatial deformities exhibited by these feet and legs, it was hypothesized that correction using the Taylor spatial frame (TSF) would decrease morbidity, facilitate correction, and minimize treatment time in children from remote regions with extremely rigid deformed feet.

Methods: Recent experience with the management of 11 such feet (Dimeglio type IV) in 9 children with an average age of 9.2 years using the TSF has been gratifying. Six children had associated leg length discrepancy, which was corrected by concomitant tibial lengthening. All feet underwent soft tissue releases, whereas forefoot and/or hindfoot osteotomies were performed in 7 feet.

Results: All children attained plantigrade, functional feet, and were fully ambulatory and capable of wearing normal footwear. Complications were minor consisting of pin tract infections, residual metatarsus varus in 3, and wound dehiscence in 1. There were no neurovascular events. This was attributed to the slower 3 plane correction using the TSF technique as well as the elimination of the need for plaster immobilization thus allowing direct monitoring of the foot and limb.

Conclusions: The rigid foot deformity in the older child can be safely and effectively corrected with the aid of the TSF, which facilitates a 3 plane correction and concomitant limb lengthening.

Keywords: Taylor spatial frame, neglected congenital deformities, limb length discrepancy

An Analysis of Outcomes after Use of the Maxwell-Brancheau Arthroereisis Implant

Authors: Steven Brancheau, DPM, Kelly Walker, DPM, and David Northcutt, DPM

Journal:  JFAS

Abstract: The authors present a retrospective study of 35 consecutive patients (60 feet) treated with the Maxwell-Brancheau Arthroereisis (MBA) implant. The mean age of the cohort at the time of surgery was 14.3 (range 5 to 46) years, and 22 (62.86%) men and 13 (37.14%) women were included. Preoperative and postoperative anteroposterior and lateral foot radiographs were compared at a mean of 36 (range 18 to 48) months postoperatively, and the following mean changes were reported: talocalcaneal angle 24.15° ± 7.97° to 18.53° ± 8.23°, calcaneocuboid angle 18.67° ± 8.72° to 11.76° ± 8.49°, first to second intermetatarsal angle 9.42° ± 2.67° to 7.61° ± 2.69°, calcaneal inclination angle 11.93° ± 6° to 14.93° ± 5.85°, and talar declination angle 34.0° ± 8.59° to 28.02° ± 6.85°; all of these differences were statistically significant (p < .0001). A subgroup of 24 (68.57%) patients also answered a subjective questionnaire at a mean of 33 (range 12 to 55) months postoperatively. The presenting chief complaints were resolved in 23 patients (95.83%) of the subgroup, and 21 patients (87.5%) returned postoperatively to either the same or a greater activity level in sports. Twenty-three (95.83% of the subgroup) patients said they were 75% to 100% satisfied with their surgical outcome, and that they would recommend the surgery to a friend or family member with the same condition, whereas 1 (4.17%) claimed 0% satisfaction after placement of inappropriately sized implants (which were later replaced to the patient’s clinical satisfaction) in both feet

Keywords:  calcaneus, flatfoot, pes valgoplanus, subtalar joint, surgery, talus

INBONE Total Ankle Replacement: Current Status

Authors: James K. DeOrio, MD

Journal:  AAOS OrthoPortal

Abstract:  The INBONE Total Ankle (Wright Medical Technology, Arlington, TN) replacement is a modular ankle replacement system consisting of an intramedullary stem whose pieces are inserted through the ankle and pushed up into the tibia to support the tibial tray of the device. The original talar component of the INBONE ankle is a saddle-shaped prosthesis that resurfaces only the top of the talus. A new talar design feature of the INBONE II ankle is a sulcus and two anterior prongs. Between the tibial and talar components of the INBONE, each consisting of a cobalt-chrome alloy, lies an ultra-high–molecular-weight polyethylene spacer locked into the tibial baseplate. In the INBONE II ankle, this polyethylene component is V shaped, to fit into the talar component of the prosthesis. This article describes the use of the INBONE ankle in total ankle arthroplasty and provides a detailed review of the surgical technique used for its achievement.

Keywords:  Total ankle arthroplasty, ankle replacement system, INBONE

Rate of nonunion after First Metatarsal-Cuneiform Arthrodesis Using Joint Curettage and Two Crossed Compression Screw Fixation

Authors: Michael P. Donnenwerth, DPM; Sara L Borkosky, DPM; Bradley P. Abicht, DPM; Elizabeth J. Plovanich, DPM; Thomas S. Roukis, DPM, PhD, FACFAS.

Journal:  JFAS

Abstract:  First metatarsal-cuneiform joint arthrodesis is a commonly performed procedure to correct first ray pathology. The most widely accepted approach is curettage and 2 crossed compression screw fixation followed by a period of non–weight-bearing. Despite adequate joint preparation and stable internal fixation, nonunion has been cited as a known complication. This can lead to the need for revision surgery, which is undesirable and drives healthcare costs. To further investigate this topic, we conducted a systematic review to determine the rate of nonunion after the first metatarsal-cuneiform joint arthrodesis using curettage and 2 crossed compression screw fixation. Studies were eligible for inclusion only if they involved the following: arthrodesis of the first metatarsal-cuneiform joint with curettage and 2 crossed compression screw fixation, a minimum of 25 feet, with a mean follow-up of at least 6 months, and a period of postoperative non–weight-bearing. After considering all the potentially eligible references, 1 (1.8%) evidence-based medicine level I and 4 (7.3%) evidence-based medicine level IV studies met our inclusion criteria. A total of 537 patients (599 feet), 54 (10%) males and 483 (90%) females, with a weighted mean age of 49.4 years, were included. For those studies that specified the exact follow-up, the weighted mean was 30.9 months. A total of 30 nonunions (5%) were reported, with 17 (56.7%) symptomatic. The results of our systematic review revealed a relatively high rate of nonunion for first metatarsal-cuneiform joint arthrodesis with curettage and 2 crossed compression screw fixation, even when performed by experienced surgeons. Therefore, given the available data, additional prospective investigations are warranted, especially in the evaluation and comparison of fixation constructs and postoperative management.

Keywords: hallux valgus, Lapidus, metatarsus primus varus, tarsal-metatarsal joint, surgery

Three-wire Fixation Technique for Displaced Fifth Metatarsal Base Fractures

Authors: James L. Thomas & Barry C. Davis

Journal: Journal of Foot and Ankle Surgery

Abstract: Fractures of the tuberosity of the fifth metatarsal are the most common type of fifth metatarsal fractures. This particular fracture usually produces low morbidity and low rates of nonunion when treated nonoperatively. However, on occasion, significant displacement, comminution, or significant intra-articular involvement may warrant operative intervention. Multiple techniques have been described for the operative care of this fracture. We present a somewhat simplified fixation method for displaced fifth metatarsal fractures in a small set of patients who were all followed up to final healing of the fracture.

Keywords: bone, foot, injury, surgery, trauma

Mechanical Comparison of Two Types of Fixation for Ludloff Oblique First Metatarsal Osteotomy

Authors: Stavros P. Tsilikas, Emmanouil D. Stamatis, Stavros K. Kourkoulis, Athanasios S. Mitousoudis, Panayiotis E. Chatzistergos, Panayiotis J. Papagelopoulos

Journal: Journal of Foot and Ankle Surgery

Abstract: The Ludloff oblique metatarsal osteotomy is an effective method to correct hallux valgus deformity, although a number of problems have been associated with it, including inherent instability, delayed union, dorsal malunion, and fixation failure. The purpose of the present study was to compare the mechanical characteristics of fixation of the Ludloff osteotomy in 20 identical synthetic bone models, 10 fixated using 2 screws (group I) and 10 fixated using 2 screws augmented with a mini locking plate (group II). Each specimen was loaded to failure, and the mean average load to failure, stiffness, and absorbed energy to failure were compared using unpaired Student’s t test. The mean average stiffness of the Ludloff osteotomy fixed with 2 screws (group I) and with the supplementary mini locking plate (group II) was 172.7 ± 31.7 N/mm and 193.3 ± 39 N/mm, respectively (p = .21). The mean average load to failure for groups I and II was 278.4 ± 64.4 N and 356.2 ± 77.9 N, respectively (p = .025). The mean average energy absorbed before failure for groups I and II was 506.7 ± 206.4 Nmm and 769.8 ± 339.4 Nmm, respectively (p = .05). The use of a medially applied supplementary mini locking plate offers a simple and effective method to improve the mechanical stability of the Ludloff oblique osteotomy.

Keywords: bone, hallux valgus, interfragmental compression screw, locking plate, surgery