Thursday, December 15, 2011

INBONE Total Ankle Replacement: Current Status

Authors: James K. DeOrio, MD
JournalAAOS 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

Sunday, December 4, 2011

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.

JournalJFAS

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.

Monday, November 21, 2011

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

Thursday, November 10, 2011

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

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.

Wednesday, November 2, 2011

Advances in Intramedullary Nail Fixation in Foot and Ankle Surgery

Authors: Woods JB, and Burns PR
Abstract: Tibiotalocalcaneal arthrodesis for the treatment of complex foot and ankle deformities are extremely challenging cases. Technological advances in intramedullary nail fixation have improved the biomechanical properties of available fixation constructs in recent years. Nails designed specifically to accommodate hindfoot anatomy, advancement in the understanding of optimal screw orientation, fixed angle technology, the availability of spiral blade screws, and features designed to achieve compression across the arthrodesis site have provided the foot and ankle surgeon with a greater armamentarium for performing tibiotalocalneal arthrodesis. Although advances may help to improve clinical results, small sample sizes and the low-level evidence of study designs limit the evaluation of how these advances affect clinical outcomes.

Wednesday, October 26, 2011

Digital Arthrodesis: Current Fixation Techniques

Authors: Jared L. Moon, Carl A. Kihm, Daniel A. Perez, Leslie B. Dowling, David C. Alder
Abstract: Several hammertoe implant devices have recently been introduced in an attempt to provide optimal fixation for proximal interphalangeal joint arthrodesis. This article reviews these implants individually, and discusses their advantages and disadvantages. There is a lack of research with long-term follow-up available for these devices. Percutaneous Kirschner-wire fixation persists as a time-honored and effective method of fixation. The buried Kirschner-wire technique is also an effective, cost-conscious option, with many of the same advantages as newer implantable devices.



Friday, October 21, 2011

Fractures of the Calcaneal Tuberosity Treated With Suture Fixation Through Bone Tunnels

Authors: Banerjee R, Chao J, Sadeghi C, Taylor R, Nickisch F.


Abstract:  Fractures of the calcaneal tuberosity, although rare, present a challenge for the treating surgeon. The goal of treatment is restoration of function of the gastrocnemius–soleus complex and the Achilles tendon. These fractures often occur in diabetics and elderly osteoporotic patients and therefore fixation of the displaced fragment is difficult. Displaced fractures, if not recognized and promptly reduced, often result in secondary soft tissue compromise. Often, the fragment is a small shell of osteoporotic bone, which is less than optimal for bony fixation. We present our technique for surgical fixation of calcaneal tuberosity fractures using a suture placed through bone tunnels in the calcaneal body. This technique is used by itself for smaller fragments or supplemented with screw fixation for larger fragments.

Keywords: calcaneus fracture, calcaneal tuberosity, calcaneal avulsion

Thursday, October 13, 2011

Evaluation of the syndesmotic-only fixation for Weber-C ankle fractures with syndesmotic injury


Authors: Mohammed R, Syed S, Metikala S, and Ali SA


AbstractBackground: With the length of the fibula restored and the syndesmosis reduced anatomically, internal fixation using a plating device may not be necessary for supra-syndesmotic fibular fractures combined with diastasis of inferior tibio-fibular joint. A retrospective observational study was performed in patients who had this injury pattern treated with syndesmosis-only fixation.
Materials and Methods: 12 patients who had Weber type-C injury pattern were treated with syndesmosis only fixation. The treatment plan was followed only if the fibular length could be restored and if the syndesmosis could be anatomically reduced. Through a percutaneous or mini-open reduction and clamp stabilization of the syndesmosis, all but one patient had a single tricortical screw fixation across the syndesmosis. Patients were kept non-weight-bearing for 6 weeks, followed by screw removal at an average of 8 weeks. Outcomes were assessed using an objective ankle scoring system (Olerud and Molander scale) and by radiographic assessment of the ankle mortise.
Results: At a mean follow-up of 13 months, the functional outcome score was 75. Excellent to good outcomes were noted in 83% of the patients. Ankle mortise was reduced in all cases, and all but one fibular fracture united without loss of fixation. Six patients had more than one malleolar injury, needing either screw or anchor fixations. One patient had late diastasis after removal of the syndesmotic screw and underwent revision surgery with bone grafting of the fibula. This was probably due to early screw removal, before union of the fibular fracture had occurred.
Conclusion: We recommend syndesmosis-only fixation as an effective treatment option for a combination of syndesmosis disruption and Weber type-C lateral malleolar fractures.

KeywordsWeber type-C ankle fractures, syndesmotic disruption, syndesmosis-only fixation, functional outcomes

Wednesday, October 5, 2011

Ankle Arthrodesis Utilizing a Single Lateral Exposure and Headless Screw Fixation


Authors: Taylor, BC


Abstract:  Ankle arthrodesis is a well-accepted treatment method for patients with severe pain and dysfunction arising from degenerative changes of the ankle joint. Many different techniques have been described and can be appropriately utilized with the proper patient presentation. In this paper, we describe a technique of ankle arthrodesis performed utilizing a single lateral incision without fibular osteotomy and employing cannulated headless compression screw technology for fixation. When compared with traditional techniques, this approach has advantages of limited soft tissue dissection and periosteal stripping, possible incorporation of a previous surgical incision, rapid healing time and return of functionality, and elimination of hardware prominence.

KeywordsAnkle arthrodesis, lateral incision, headless screw

Monday, September 26, 2011

Fractures of the Proximal Fifth Metatarsal: Percutaneous Bicortical Fixation


Authors: Vivek Mahajan, MD, Hyun Wook Chung, MD, and Jin Soo Suh, MD


Abstract: 
Background: Displaced intraarticular zone I and displaced zone II fractures of the proximal fifth metatarsal bone are frequently complicated by delayed nonunion due to a vascular watershed. Many complications have been reported with the commonly used intramedullary screw fixation for these fractures. The optimal surgical procedure for these fractures has not been determined. All these observations led us to evaluate the effectiveness of percutaneous bicortical screw fixation for treating these fractures.
Methods: Twenty-three fractures were operatively treated by bicortical screw fixation. All the fractures were evaluated both clinically and radiologically for the healing. All the patients were followed at 2 or 3 week intervals till fracture union. The patients were followed for an average of 22.5 months. Results: Twenty-three fractures healed uneventfully following bicortical fixation, with a mean healing time of 6.3 weeks (range, 4 to 10 weeks). The average American Orthopaedic Foot & Ankle Society (AOFAS) score was 94 (range, 90 to 99). All the patients reported no pain at rest or during athletic activity. We removed the implant in all cases at a mean of 23.2 weeks (range, 18 to 32 weeks). There was no refracture in any of our cases.
Conclusions: The current study shows the effectiveness of bicortical screw fixation for displaced intraarticular zone I fractures and displaced zone II fractures. We recommend it as one of the useful techniques for fixation of displaced zone I and II fractures.
KeywordsFifth metatarsal, Proximal metatarsal fracture, Percutaneous fixation, Bicortical fixation.

Tuesday, September 20, 2011

Total Ankle Replacement with Use of a New Three-Component Implant


Authors: Pascal F. Rippstein, MD; Martin Huber, MD; J. Chris Coetzee, MD; Florian D. Naal, MD


Abstract
BackgroundTotal ankle arthroplasty has evolved over the past decade, and newer three-component implants have demonstrated favorable clinical results and improved survivorship. The present study analyzed the clinical and radiographic results of the first 240 total ankle arthroplasties performed by the authors with one of these new three-component prostheses. MethodsTwo hundred and forty consecutive primary total ankle arthroplasties were performed in 233 patients (115 women and 118 men; mean age, 61.6 years) between November 2003 and October 2007 with the Mobility prosthesis. Intraoperative and postoperative complications, reoperations, and failures were recorded. The American Orthopaedic Foot & Ankle Society hindfoot score and a visual analog scale score assessment of pain were determined at each follow-up visit. Range of ankle motion was measured on functional radiographs, and the radiographs were studied to assess component positioning, radiolucencies, new bone formation, and periprosthetic bone cysts.  ResultsTwo hundred and thirty-three of the arthroplasties were available for follow-up at least one year after surgery. The mean duration of follow-up was 32.8 ± 15.3 months. There were ten intraoperative complications (4.2%) and twenty postoperative complications (8.6%). A reoperation was necessary in eighteen ankles (7.7%). Five arthroplasties (2.1%) failed at a mean of twenty-seven months after surgery. The mean American Orthopaedic Foot & Ankle Society hindfoot score improved from 48.2 to 84.1 points (p < 0.001). The mean pain level decreased from 7.7 to 1.7 points (p < 0.001). The mean total range of ankle motion improved from 19.8° to 21.9° (p < 0.001). The tibial component had a mean of 2.1° of varus and a mean posterior slope of 6.0° relative to the tibial axis. The prevalence of nonprogressive radiolucency ranged from 1.8% to 37.3% in the ten zones surrounding the tibial component, and from 0 to 2.2% in the three zones surrounding the talar component. ConclusionsThe short-term clinical and radiographic results after Mobility total ankle arthroplasty are encouraging and are at least comparable with those associated with other modern three-component implants. The minimum duration of follow-up of one year is short, and studies with longer follow-up are needed to confirm our findings.

Wednesday, September 7, 2011

Functional Outcomes after Fibula Locking Nail for Fragility Fractures of the Ankle


Authors: Aysha Rajeev, Shanaka Senevirathna, Sarkhell Radha, and N.S. Kashayap


Abstract:  The aim of the present study was to assess the functional outcome of fragility fractures of the ankle treated with a fibular locking nail. A retrospective review of 24 patients with fragility fractures treated with a fibular locking nail from January 2005 to December 2007 was performed. The fibular nail used in our study was Biomet SST (stainless steel taper) small bone locking nail for the fibula. The Olerud and Molander scale was used to assess the functional outcome at the end of 1 year. The domains of the Olerud and Molander scale are pain, stiffness, swelling, stair climbing, running, jumping, squatting, support, and the activities of daily living. The patients were interviewed by telephone or the questionnaire was send by mail. Of the 24 patients, 2 were men and 22 were women. The left side was affected in 15 patients. The age group ranged from 71 to 91 years (average, 79). Of the fractures, 10 were lateral alveolus, 8 were bimalleolar, and 6 were trimalleolar fractures. All the patients were followed up at 6 weeks, 12 weeks, and after 6 months. The average period to fracture union was 8.7 weeks. No wound breakdown or any deep infections developed. The average Olerud and Molander scale score was 57 (range 30 to 65). The use of fibular locking nails to treat these difficult fracture are quite crucial to achieve early mobilization and also to maintain a good fracture position. In our study, the use of fibular nails was a very useful and successful method of treating fragility fractures with a very low risk of 
complications. It also helps to restore function and results in patient satisfaction.

Monday, August 29, 2011

The Taylor Spatial Frame for Correction of Neglected Fracture Dislocation of the Ankle

Authors: Ravikiran Shenoy, George Kubicek, Michael Pearse
Treatment of neglected fracture dislocations of the ankle poses a surgical challenge. Extensive open reduction can frequently be contraindicated because of local skin conditions and contractures. The Taylor Spatial Frame™ (TSF) has been used to reduce and maintain reduction of complex fractures. Its use in fracture dislocation of the ankle joint has not been described. We describe a case where a TSF was used to reduce and treat a 6-week-old fracture dislocation of the ankle. The TSF is a versatile device, which has a role in the management of both acute and neglected fractures.

Monday, August 22, 2011

Medial Malleolar Fractures: A Biomechanical Study of Fixation Techniques




Authors: T. Ty Fowler, MD; Kevin J. Pugh, MD; Alan S. Litsky, MD, ScD; Benjamin C. Taylor, MD; Bruce G. French, MD


Fracture fixation of the medial malleolus in rotationally unstable ankle fractures typically results in healing with current fixation methods. However, when failure occurs, pullout of the screws from tension, compression, and rotational forces is predictable. We sought to biomechanically test a relatively new technique of bicortical screw fixation for medial malleoli fractures. Also, the AO group recommends tension-band fixation of small avulsion type fractures of the medial malleolus that are unacceptable for screw fixation. A well-documented complication of this technique is prominent symptomatic implants and secondary surgery for implant removal. Replacing stainless steel 18-gauge wire with FiberWire suture could theoretically decrease symptomatic implants. Therefore, a second goal was to biomechanically compare these 2 tension-band constructs.
Using a tibial Sawbones model, 2 bicortical screws were compared with 2 unicortical cancellous screws on a servohydraulic test frame in offset axial, transverse, and tension loading. Second, tension-band fixation using stainless steel wire was compared with FiberWire under tensile loads. Bicortical screw fixation was statistically the stiffest construct under tension loading conditions compared to unicortical screw fixation and tension-band techniques with FiberWire or stainless steel wire. In fact, unicortical screw fixation had only 10% of the stiffness as demonstrated in the bicortical technique. In a direct comparison, tension-band fixation using stainless steel wire was statistically stiffer than the FiberWire construct.

Key words: Medial Malleolar Fractures, Ankle Fracture Fixation Techniques

Monday, August 15, 2011

Distal Femoral Locking Plates for Tibiotalocalcaneal Fusions in the Charcot Ankle: A retrospective study



Authors: Sarah Shogren, DPM , Sara Zelinskas, DPM , Byron Hutchinson, DPM , Vineet Kamboj, DPM


This paper presents a retrospective case series with chart and radiographic review of four patients with Charcot neuroarthropathy and associated ankle valgus. All four patients underwent tibiotalocalcaneal (TTC) arthrodesis using a distal femoral locking plate combined with external ring fixation for rigid axial compression. A 12 month follow-up was obtained. All four TTC arthrodeses were performed by the same surgeon (BH) including preoperative and postoperative evaluation and care. Outcomes were deemed successful with evidence of radiographic consolidation across the fusion sites. Outcomes were considered failures in the presence of non-union or amputation. Three patients had satisfactory outcomes with only minor complications. One patient had failure of the procedure with development of osteomyelitis and ultimately had a below knee amputation. Although this was a small review, on average, osseous consolidation was appreciated in 77 days for those patients that had successful outcomes. Larger retrospective or even prospective studies are needed to confirm the use of tibiotalocalcaneal arthrodesis using a distal femoral locking plate and external ring fixation in Charcot arthropathy. This small case series shows promise to the efficacy of distal femoral locking plates for tibiotalocalcaneal fusions.
Key words: Tibiotalocalcaneal fusions, Charcot Ankle, distal femoral locking plates, ankle valgus

Monday, August 8, 2011

Current Concepts Review: Results of Total Ankle Arthroplasty


Authors: Mark E. Easley, MD; Samuel B. Adams, MD; W. Chad Hembree, MD; James K. DeOrio, MD


Most published reports related to total ankle arthroplasty have a fair to poor-quality level of evidence.
Comparative studies with a fair to good-quality level of evidence suggest that total ankle arthroplasty provides equal pain relief and possibly improved function compared with ankle arthrodesis.
On the basis of the current literature, survivorship of total ankle arthroplasty implants, when measured as the retention of metal components, ranges from 70% to 98% at three to six years and from 80% to 95% at eight to twelve years.
Several investigators have argued that, in the evolution of total ankle arthroplasty, some obligatory reoperation without removal of the metal implants is anticipated; examples of reoperation include relief of osseous or soft-tissue impingement, improvement of alignment or stability of the foot and ankle, bone-grafting for cystic lesions, and/or polyethylene exchange.
A successful return to low-impact, recreational sporting activities is possible after total ankle arthroplasty.

Key words: N/A

Monday, July 25, 2011

Locked Versus Nonlocked Plate Fixation For Hallux MTP Arthrodesis

Authors: Kenneth J. Hunt, MD; J. Kent Ellington, MD, MS; Robert B. Anderson, MD; Bruce E. Cohen, MD.


Dorsal plate fixation is used commonly for arthrodesis of the hallux
first metatarsophalangeal (MTP) joint. Custom dorsal plates
incorporating locking technology have been developed recently for
applications in the foot to provide relative ease of application and
theoretically superior mechanical properties. The purpose of this study
is to compare the radiographic and clinical outcomes of patients
undergoing hallux MTP joint arthrodesis using a locked plate, or a
nonlocked plate. Materials and Methods: We compared consecutive
patients who underwent hallux MTP arthrodesis for a variety of
diagnoses with either a precontoured locked titanium dorsal plate
(Group 1) or a precontoured, nonlocked stainless steel plate (Group 2).
All patients were evaluated with radiographs, visual analog pain scale,
American Orthopaedic Foot and Ankle Society (AOFAS) hallux score, and a
detailed patient satisfaction survey. Results: There were 73 feet in
Group 1 and 107 feet in Group 2. There was a trend toward a higher
nonunion rate in Group 1 compared to Group 2. When considering
only patients without rheumatoid arthritis (RA), the union rate was
significantly higher in Group 2 compared to Group 1. Hardware failure
and the overall complication rate was equivalent between the two
Groups. Conclusion: As locked plate technology continues to gain
popularity for procedures in the foot, it is important that clinical
outcomes are reported. Locked titanium plates were associated with
higher nonunion rates. Improved plate design, patient selection, and an
understanding of plate biomechanics in this unique loading environment
may optimize future outcomes for hallux MTP arthrodesis.

Level of Evidence: III, Retrospective Comparative Study

Key Words: Hallux Arthrodesis; Hallux Valgus; Hallux Rigidus; Locked
Plate; Arthritis

Monday, July 18, 2011

Lapidus Arthrodesis with a Single Lag Screw and a Locking H-Plate

Authors:  Christopher R.D. Menke, DPM; Michael C. McGlamry, DPM; Craig A. Camasta, DPM



The aim of this pilot study was to assess if using an interfragmental lag screw and a Darco® locking H-plate for the modified Lapidus arthrodesis in the treatment of hallux abducto valgus deformity (1) would allow for earlier weight bearing than previously described and (2) would indicate whether any changes would occur radiographically with the earlier weight bearing. Twenty-one metatarsocuneiform arthrodeses, in 18 patients, were retrospectively evaluated through chart review and postoperative radiographs. Original diagnoses included painful hallux abducto valgus and osteoarthritis of the first metatarsocuneiform joint. The mean age of the patients was 48 (range, 16 to 70) years. The mean follow-up duration was 38.5 (range, 29 to 60) months. The overall radiographic osseous union rate was 90.5% (19/21 feet), although there were 2 asymptomatic nonunions. There were no cases of fixation failure, and the surgical correction was preserved on follow-up radiographs. Overall, the mean time to full weight bearing was 4.7 (range, 3 to 7.5) weeks, and it was a mean of 8 (range, 7 to 10) weeks before the patient was back to wearing comfortable shoes. The authors concluded that metatarsocuneiform arthrodesis fixated with 1 interfragmentary lag screw and a Darco® locking H-plate provides sufficient stability to allow earlier weight bearing than has been previously described with other internal fixation constructs.
Level of Clinical Evidence: 4

Monday, July 11, 2011

Posterior Approach Using Anterior Ankle Arthrodesis Locking Plate for Tibiotalocalcaneal Arthrodesis

Authors:  Lawrence A. DiDomenico, DPM; Paul Sann, DPM

 

Tibiotalocalcaneal arthrodesis is a successful treatment for patients with severe pain and functional disability in the ankle and subtalar joint. Patients with post-traumatic ankle and subtalar joint arthritis, and/or Charcot deformity, often present with compromised skin and soft tissue structures. In the present report, we describe a technique using an anterior ankle arthrodesis locking plate placed posteriorly to obtain hindfoot and ankle fusion. This technique, which uses the well vascularized, thick, posterior soft tissue envelope, provides very good exposure of the articular surfaces for resection and tibiotalocalcaneal fusion. The technique provides a valuable option for patients with compromised skin and soft tissue structures over aspects of the ankle that make other approaches risky and complicated.