Minifragment Plate Fixation of High-Energy Navicular Body Fractures

Jason Evans, MD; Daphne M. Beingessner, MD; Julie Agel, MA; Stephen K. Benirschke, MD

Foot & Ankle International: May 2011 (Vol.32 #5) May 1, 2011

The purpose of this study was to assess the ability of miniplate

fixation in navicular fractures to restore medial column stability,

maintain reduction, and determine the impact this approach may have on

the development of avascular collapse of the navicular. We hypothesized

that comminuted fractures of the navicular can be safely reduced and

maintained to union with minifragment plate fixation with a low

incidence of avascular collapse. Materials and Methods: A retrospective

chart review was performed on 24 patients with navicular

fractures treated with open reduction and internal fixation with

minifragment plate fixation at a level one trauma center over a period

of 6 years. Results: All fractures united. No patient developed a deep

infection. There was no loss of reduction. Isolated broken screws were

evident in three patients (12.5%), with no plate breakage, and no

implant failure by pullout. Four patients (17%) underwent plate removal

for painful prominent hardware following fracture healing. Four

patients (17%) developed radiographic arthrosis of the talonavicular

joint. One patient (4%) had radiographic avascular collapse evident at

6 months and was treated with plate removal and an

orthotic device. Conclusion: Minifragment fixation was a good

alternative to independent lag screws for rigid stabilization of

navicular body fractures

Level of Evidence: IV, Retrospective Case Series

Key Words: Navicular; Avascular Necrosis; Talonavicular Arthritis;

Midfoot Injuries; High-Energy

STAR™ Ankle: Long-Term Results

Jeffrey A. Mann, MD; Roger A. Mann, MD; Eric Horton, MD

Foot & Ankle International: May 2011 (Vol.32 #5) May 1, 2011

There has been a resurgence of interest in total ankle replacement

(TAR) due to improved results with newer prostheses. However, long-term

survivorship data has been limited. The STAR™ Ankle prosthesis is the

first three-part prosthesis approved for use in the United States.

Materials and Methods: Eighty-four total ankle replacements were

performed in 80 patients using the STAR™ Ankle prosthesis and followed

prospectively. Postoperatively, patients were evaluated with the AOFAS

score for pain and function, and serial radiographs were evaluated for

stability and alignment of the prosthesis. Implant failure, secondary

procedures, and complications were recorded. Results: Ninety-one

percent of prostheses remain implanted at an average followup of 9.1

years. The probability of implant survival was 96% at 5 years and 90%

at 10 years. An average 39-point improvement in the AOFAS

ankle-hindfoot score was noted, from a mean of 43 to a mean of 82

points. We noted a statistically significant increase in both average

pain and function sub-scores. Postoperative range of motion averaged

4.5 degrees of dorsiflexion and 35 degrees of plantarflexion. Ninetytwo

percent of the patients were satisfied with their outcome. Ten patients

(13%) developed concerning osteolytic lesions. Change in prosthetic

alignment and adjacent joint arthritis were similar to previous

reports. We report 21 complications, which included 14 additional

surgical procedures. Conclusion: The first U.S. prospective long-term

survivorship data with the STAR™ Ankle prosthesis found it to be an

excellent long-term option for the treatment of ankle arthritis.

Level of Evidence: IV, Case Series

Key Words: Ankle Arthroplasty; Ankle Arthritis; Scandinavian Total

Ankle Replacement; STAR Ankle  

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Hardware Related Pain and Hardware Removal after Open Reduction and Internal Fixation of Ankle Fractures

Johan H. Pot, Remco J.A. van Wensen, Jan G. Olsman 

The Foot and Ankle Online Journal 4 (5): 1 May 2011

Fractures of the distal tibia and fibula are one of the most common types of fractures in adults. [1] Whereas stable and non or minimally displaced fractures can be treated with cast immobilization, unstable dislocated ankle fractures require open reduction and internal fixation (ORIF) with plate and screws.

Long term functional outcome is satisfying in most patients, but a number of patients have persistent ‘hardware related’ complaints and tenderness that ‘require’ elective hardware removal. Aside from painful hardware, some asymptomatic patients also want their hardware removed for other reasons. Although hardware removal is frequently undertaken, it is not without risk and the results are often unpredictable. [2]

The more commonly reported risks of hardware removal are iatrogenic (nerve) injury, infections, delay in wound healing and re-fractures. In addition to medical considerations there is also an economic impact such as physician costs, hospital fees, patient loss of work and productivity. [2] Reports in literature are not consistent concerning the incidence of painful hardware and the outcome and pain relief after hardware removal. [3-5] This study was designed to document the incidence of late pain after ORIF of ankle fractures and to analyse the outcome, expectations and complications after hardware removal.

Key words: Ankle, Ankle Fracture, FAOS, Hardware, ORIF Ankle

See all of your internal and external fixation options for Ankle Fracture, Fibular Fracture, Medial Malleolar Fracture, and Pilon Fracture. 

Retrograde Ankle Arthrodesis Using an Intramedullary Nail: A Comparison of Patients with and without Diabetes Mellitus

Dane K. Wukich, MD1, James Y.C. Shen, MD2, Claudia P. Ramirez, BS2, James J. Irrgang PhD, PR, ATC3

The Journal of Foot and Ankle Surgery: Volume 50, Issue 3, Pages 299-306 (May 2011)

Tibiotalocalcaneal arthrodesis (TTCA) has been used for the salvage of severe deformity involving the ankle and hindfoot. The purpose of this study was to evaluate the results of retrograde intramedullary nailing (IMN) for severe ankle/hindfoot pathology in a group of patients with diabetic neuropathy and compare them with a cohort of nondiabetic patients. Our working hypothesis was that patients with diabetes mellitus (DM) and neuropathy would experience inferior outcomes and more postoperative complications than patients who did not have DM. Forty consecutive patients (17 with DM and 23 without DM) who had a minimum follow-up of 1 year were retrospectively reviewed. The mean follow-up was 33 months and the mean AOFAS Ankle Hindfoot Score significantly improved form 19 to 55. Patients with DM improved on average from 24 to 55 and patients without DM improved from 16 to 55. Although a postoperative complication was experienced in 59% of patients with DM compared with 44% of patients without DM, this difference did not reach statistical significance with the numbers available. More patients with DM used a brace at final follow-up than patients without DM. Those patients who had a history of preoperative skin ulceration had higher rates of infection than those patients who did not have skin ulcers. We did not find any significant postoperative differences in AOFAS Ankle Hindfoot Scores between those patients with DM versus patients without DM. On average, patients with DM demonstrated an improvement of 129% and patients without diabetes improved by 243%. With the numbers available, we were not able to confirm our hypothesis that patients with DM experienced significantly lower clinical outcomes than patients without DM. A study of 100 patients in each group would be necessary to achieve adequate power to conclusively state that DM had no impact on the final outcome.

Level of Clinical Evidence: 2

Keywords: ankle, arthrodesis, diabetes, nail

Check all of your Intramedullary Nail options for Pantalar / Tibiotalocalcaneal Arthrodesis here.

1 Chief, Division of Foot and Ankle Surgery; Associate Professor of Orthopaedic Surgery; and Assistant Program Director, Orthopaedic Surgery Residency, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA

2 Medical Student, University of Pittsburgh School of Medicine, Pittsburgh, PA

3 Associate Professor of Orthopaedic Surgery and Director of Clinical Research, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA

Cannulated Screw Fixation of Jones Fifth Metatarsal Fractures: A Comparison of Titanium and Stainless Steel Screw Fixation

J. George DeVries, DPM, AACFAS 1, Daniel J. Cuttica, DO 2, Christopher F. Hyer, DPM, FACFAS 3

The Journal of Foot & Ankle Surgery: 50 (2011) 207–212

The classic Jones fracture involves the fifth metatarsal at the level of the proximal diaphyseal-metaphyseal junction. The mainstay of surgical treatment for the Jones fracture is intramedullary screw fixation. There is no consensus of the type or material of screw that should be used. The purpose of this retrospective cohort study was to test the hypothesis that there is no clinical difference in the incidence of healing, or complica- tions, when comparing stainless steel to titanium cannulated screws used in Jones fracture open-reduction internal fixation (ORIF). Data were collected on a total of 53 patients (fractures) that were fixed with either cannulated titanium screws (Ti group) or cannulated stainless steel screws (SS group). The postoperative protocol was standardized. The mean time to radiographic union was 11.7 ` 5.1 weeks in the Ti group and 13.4 ` 5.7 weeks in the SS group (P 1⁄4 .333). The overall union rate for the Ti group was 36/37 (97%) and 14/16 (88%) in the SS group (P 1⁄4 .213). Complications were rare in both groups, and the prevalence was not statistically significantly different (P > .05). There was 1 patient with an asymptomatic radiographic nonunion in the Ti group, and this patient elected not to undergo revision. There were 2 nonunions in the SS group. One was revised and went on to heal and the other is awaiting revision. Our study has demonstrated the decision to use stainless steel or titanium can be left to patient constraints, such as allergies, or physician preference without compromising the clinical result.

Level of Clinical Evidence: 3 

Keywords: biomechanics injury ORIF nonunion surgery trauma

1 Staff Surgical Podiatrist, Ripon Medical Center, Ripon, WI 

2 Orthopaedic Surgeon, Center for Orthopaedic Surgery and Sports Medicine, Indianapolis, IN 

3 Fellowship Co-director, Advanced Foot and Ankle Surgery Fellowship, Orthopedic Foot and Ankle Center, Westerville, OH

Early Clinical and Radiographic Outcomes after Treatment of Displaced Intra-articular Calcaneal Fractures Using Delta-Frame External Fixator Construct

Charles G. Kissel, DPM, FACFAS 1, Zeeshan S. Husain, DPM, FACFAS 2, James M. Cottom, DPM, FACFAS 3, Ryan T. Scott, DPM 4, Joshua Vest, DPM 5

The Journal of Foot & Ankle Surgery: 50 (2011) 135–140

Intra-articular calcaneal fractures are associated with high morbidity, persistent pain, and long-term disability. This retrospective study assesses early clinical and radiographic postoperative findings of intra-articular calcaneal fractures following treatment by ligamentotaxis using a delta frame construct with a large frag- ment external fixator. Minimally invasive percutaneous reduction of calcaneal fractures is an alternative treatment for Sanders type II, III, and IV fractures. Ten patients from the Detroit Medical Center were followed between January 2002 and December 2004 for follow-up over a mean of 353.5 ` 85.45 days postoperatively. The mean age of the patients was 45.8 ` 12.3 years. There were 2 patients with Sanders type IIA, 3 patients with type IIIAB, 1 patient with type IIIAC, and 4 patients with type IV fracture patterns. The results demon- strated that the mean calcaneal width decreased, the calcaneal height increased, and the calcaneal length increased when comparing preoperative to postoperative measurements. Bo€hler’s angle increased from 20.8 ` 8.27 preoperatively to 25.7 ` 5.21 postoperatively, and Gissane’s angle decreased from 127.4 ` 45.22 preoperatively to 111.2 ` 39.38 postoperatively. The posterior facet step-off on CT examination reduced from 2.6 ` 0.82 mm preoperatively to 0.4 ` 0.26 mm postoperatively. The mean postoperative total subtalar joint range of motion was 19.0 ` 4.5 on the affected side and 34.4 ` 4.58 on the contralateral foot. The mean Maryland Foot score was 85.8 ` 6.41 in the 10 patients. With the exception of the change from preoperative to postoperative Bo€hler’s angle, and the comparison of the ipsilateral (side of the fracture) to contralateral resting calcaneal stance position, all of the comparisons revealed statistically significant (P .05) differences. The authors conclude that the delta frame construct is a viable alternative method to open reduction and internal fixation for treating intra-articular calcaneal fractures.

Level of Clinical Evidence: 4 

Keywords: distraction frame heel ligamentotaxis trauma

1 Detroit Medical Center PM&S-36 Residency Program Director, Detroit, MI 

2 Detroit Medical Center PM&S-36 Assistant Residency Director, Detroit, MI 

3 Submitted during residency, Detroit Medical Center PM&S-36, Detroit, MI 

4 Submitted during residency, Detroit Medical Center PM&S-36, Detroit, MI 

5 Submitted during residency, Detroit Medical Center PM&S-36, Detroit, MI

Medial Column Rodding Facilitated by Transitional Osteochondral Graft

Jeremy Cook, DPM, MPH, Emily Cook DPM, MPH, Philip Basile, DPM

Foot and Ankle Specialist: Foot Ankle Spec April 2011 vol. 4 no. 2, 106-111

This is a case report using a new technique designed to allow passage of a screw through a joint while simultaneously preserving the joint cartilage. A 58-year-old woman with diabetes with midfoot Charcot neuro-arthropathy underwent reconstruction, which included a medial column rodding. A headless 8.0-mm screw was inserted into the first metatarsal head coursing along the entire medial column after temporary removal of a portion of the osteochondral surface. This allowed the screw to be positioned perpendicular to the medial column joints. Serial radiographs were collected to evaluate alignment, stability, and osteochondral graft incorporation. The patient showed preservation of joint motion and function with complete osteochondral graft incorporation without evidence of joint degeneration or pain after 45 months of follow-up. This is the first study to present the use of a local osteochondral graft to allow passage of a large diameter screw in the foot. Although graft incorporation was complete, the situation regarding joint preservation remains unclear, but midterm follow-up shows promise.

Levels of Evidence: Therapeutic, Level IV, retrospective case study