Corrective ankle osteotomies

Restoration of the patient-specific anatomy of the distal fibula based on a novel three-dimensional contralateral registration method

Purpose

Posttraumatic fibular malunion alters ankle joint biomechanics and may lead to pain, stiffness, and premature osteoarthritis. The accurate restoration is key for success of reconstructive surgeries. The aim of this study was to analyze the accuracy of a novel three-dimensional (3D) registration algorithm using different segments of the contralateral anatomy to restore the distal fibula.

Methods

Triangular 3D surface models were reconstructed from computed tomographic data of 96 paired lower legs. Four segments were defined: 25% tibia, 50% tibia, 75% fibula, and 75% fibula and tibia. A surface registration algorithm was used to superimpose the mirrored contralateral model on the original model. The accuracy of distal fibula restoration was measured.

Results

The median rotation error, 3D distance (Euclidean distance), and 3D angle (Euler’s angle) using the distal 25% tibia segment for the registration were 0.8° (− 1.7–4.8), 2.1 mm (1.4–2.9), and 2.9° (1.9–5.4), respectively. The restoration showed the highest errors using the 75% fibula segment (rotation error 3.2° (0.1–8.3); Euclidean distance 4.2 mm (3.1–5.8); Euler’s angle 5.8° (3.4–9.2)). The translation error did not differ significantly between segments.

Conclusion

3D registration of the contralateral tibia and fibula reliably approximated the premorbid anatomy of the distal fibula. Registration of the 25% distal tibia, including distinct anatomical landmarks of the fibular notch and malleolar colliculi, restored the anatomy with increasing accuracy, minimizing both rotational and translational errors. This new method of evaluating malreductions could reduce morbidity in patients with ankle fractures.

Level of evidence

IV

Efficacy and Reliability of Percutaneous Gigli Saw Osteotomy in Midfoot Surgery: A Cadaver Study

BACKGROUND

Midfoot osteotomy is often used in the surgical treatment of foot deformities. The percutaneous Gigli saw osteotomy (PGSO) technique has many advantages compared with known osteotomy techniques. We aimed to show the efficacy and reliability of the PGSO technique in the midfoot of fresh frozen cadavers without using an image intensifier.

METHODS

Four mini-incisions were performed on the dorsomedial, dorsolateral, plantar medial, and plantar lateral regions of the midfoot. Subperiosteal tunnels were then opened with a thin bone elevator, and the four incisions were combined with each other. The Gigli saw was tied to suture material and passed through the tunnels. The PGSO was performed in the midfoot of 12 feet of the cadaver specimens without using an image intensifier. Cadaver specimens were dissected, and injured structures were noted.

RESULTS

The mean ± SD (range) cadaver age was 81.16 ± 10.38 years (65-93 years) and weight was 60.86 ± 12.39 kg (49.8-81.6 kg). All of the osteotomies were adequate as planned in the cuboid-cuneiform level and all of them were complete osteotomy .Incomplete osteotomy was not observed in any cadaver specimens. In one specimen, a complete injury of the peroneal tendons (peroneus longus and brevis) was detected. In another specimen, an incomplete tibialis anterior tendon injury was detected. There was no iatrogenic neurovascular injury in the specimens.

CONCLUSIONS

The PGSO technique is recommended for use even by inexperienced surgeons owing to its minimal risk of soft-tissue injury, provision of a complete osteotomy line, and easy application with limited incisions.

Emerging Concepts in Treating Cartilage, Osteochondral Defects, and Osteoarthritis of the Knee and Ankle

The management and treatment of cartilage lesions, osteochondral defects, and osteoarthritis remain a challenge in orthopedics. Moreover, these entities have different behaviors in different joints, such as the knee and the ankle, which have inherent differences in function, biology, and biomechanics. There has been a huge development on the conservative treatment (new technologies including orthobiologics) as well as on the surgical approach. Some surgical development upraises from technical improvements including advanced arthroscopic techniques but also from increased knowledge arriving from basic science research and tissue engineering and regenerative medicine approaches. This work addresses the state of the art concerning basic science comparing the knee and ankle as well as current options for treatment. Furthermore, the most promising research developments promising new options for the future are discussed.

Reconstructive Osteotomy for Ankle Malunion Improves Patient Satisfaction and Function

Treatment of chronic symptoms caused by a malunion is a difficult problem in orthopedic surgery. We encountered a case of ankle malunion at our hospital about 1 year after the first operation. The patient had been unable to walk with weight-bearing but regained the ability to walk after reconstructive osteotomy of the fibula. Functional scores for the foot and ankle were significantly improved after intervention. Reconstructive osteotomy appears to represent a good option for ankle malunion.

The varus ankle and instability

Varus ankle associated with instability can be simple or complex. Multiple underlying diseases may contribute to this complex pathologic entity. These conditions should be recognized when attempting proper decision-making. Treatment options range from conservative measures to surgical reconstruction. Whereas conservative treatment might be a possible approach for patients with simple varus ankle instability, more complex instabilities require extensive surgical reconstructions. However, adequate diagnostic workup and accurate analysis of varus ankle instability provide a base for the successful treatment outcome.

Reconstructive osteotomy of fibular malunion: review of the literature

The treatment of ankle fractures has a primary goal of restoring the full function of the injured extremity. Malunion of the fibula is the most common and most difficult ankle malunion to reconstruct. The most frequent malunions of the fibula are shortening and malrotation resulting in widening of the ankle mortise and talar instability, which may lead to posttraumatic osteoarthritis. The objective of this article is to review the literature concerning the results of osteotomies for correcting fibular malunions and to formulate recommendations for clinical practice. Based on available literature, corrective osteotomies for fibular malunion have good or excellent results in more than 75% of the patients. Reconstructive fibular osteotomy has been recommended to avoid or postpone sequela of posttraumatic degeneration, an ankle arthrodesis or supramalleolar osteotomy. The development of degenerative changes is not fully predictable; therefore, it is advisable to reconstruct a fibular malunion soon after the diagnosis is made and in presence of a good ankle function. Recommendations were made for future research because of the low level of evidence of available literature on reconstructive osteotomies of fibular malunions.

Corrective midfoot osteotomies

Corrective midfoot osteotomies involve complete separation of the forefoot and hindfoot through the level of the midfoot, followed by uni-, bi-, or triplanar realignment and arthrodesis. This technique can be performed through various approaches; however, in the high-risk patient, percutaneous and minimum incision techniques are necessary to limit the potential of developing soft tissue injury. These master level techniques require extensive surgical experience and detailed knowledge of lower extremity biomechanics. The authors discuss preoperative clinical and radiographic evaluation, specific operative techniques used, and postoperative management for the high-risk patient undergoing corrective midfoot osteotomy.

Alternatives to ankle implant arthroplasty for posttraumatic ankle arthrosis

Various surgical options beyond implant arthroplasty are available to treat posttraumatic ankle arthrosis. Conservative options are usually employed in combination and include the use of nonsteroidal anti-inflammatories, bracing, and orthoses, as well as injections of intra-articular corticosteroid and hyaluronic acid. If these conservative treatments fail, surgical intervention can be entertained. Alternatives to total ankle implant arthroplasty include (1) arthroscopic debridement, (2) arthrodiastasis, (3) peri-articular resurfacing using allograft or cartilage transplantation, and (4) peri-articular osteotomies to correct angular, rotational, or translational malalignment. However, ankle arthrodesis is the standard technique for end-stage ankle arthrosis. This article reviews the literature and presents an in-depth surgical technique for each procedure. The article also describes how to prevent and address the most common complications.

Determining the insertion site for retrograde intramedullary nail fixation of tibiotalocalcaneal arthrodesis: a radiographic and intraoperative anatomical landmark analysis

Literature regarding the optimal entry point at the plantar aspect of the heel for performing tibiotalocalcaneal arthrodesis with a locked retrograde intramedullary nail is plentiful, but fails to provide meaningful guidance beyond broad generalizations. Because of the complex nature of the procedure, which requires precise alignment of multiple joints, difficulties in guide-wire placement frequently arise. Furthermore, proper guide-wire placement is usually performed under image intensification, placing the patient, surgeon, and operating room personnel at risk of ionizing radiation. This study evaluates weight-bearing lateral radiographic and anatomical landmarks to determine the optimal guide-wire entry point at the plantar heel fat pad, as well as a prospective intraoperative evaluation of the efficacy of using these landmarks to properly seat the guide wire. Radiographic and anatomical landmark portions of the study revealed that the calcaneocuboid joint was located 18.5+/-3.4 mm anterior to the tibia mid-diaphyseal line, and that the lower leg soft tissue outline approximated the calcaneocuboid joint to within 0.3+/-1.2 mm. The intraoperative portion of the study revealed that by first aligning the guide wire with the lower leg soft tissue outline, which approximated the location of the calcaneocuboid joint, and then translating the wire approximately 2.0 cm posteriorly, the increase in the efficacy of properly seating the guide wire was statistically significant (P<or=.0001). The author proposes that this technique improves the accuracy of guide-wire placement and decreases dependency on intraoperative image intensification.