Screw hole preparation in foot surgery

First Tarsometatarsal Joint Derotational Arthrodesis for Flexible Hallux Valgus: Results from Follow-Up of 3-8 Years

PURPOSE

We report 3- to 8-year follow-up results for the first tarsometatarsal joint derotational arthrodesis.

METHODS

A total of 70 patients (88 feet) with symptomatic flexible hallux valgus were operated between 2003 and 2009. In all, 66 patients (94.3%) with 84 (95.5%) feet were enrolled in retrospective analysis; of those, 58 (87.9%) patients with 76 (90.5%) feet were followed for a mean of 5.1 (range: 3.0-8.3) years. Preoperative, 6 week postoperative, and late follow-up weightbearing radiographs were evaluated along with clinical examination and questionnaires.

RESULTS

The mean hallux valgus angle improved 13.4° (95% confidence interval: 11.6-15.1, p < .001) at the latest follow-up, while the mean intermetatarsal angle correction was 4.5° (95% confidence interval: 3.7-5.2, p < .001). There were three (4.0%) nonunions, and seven (9.2%) feet needed reoperation during follow-up.

CONCLUSION

First tarsometatarsal joint derotational arthrodesis is an effective procedure for correcting flexible hallux valgus deformity and provides a satisfactory long-term outcome.

Intraosseous fixation compared to plantar plate fixation for first metatarsocuneiform arthrodesis: a cadaveric biomechanical analysis

BACKGROUND

Metatarsocuneiform (MTC) fusion is a treatment option for management of hallux valgus. We compared the biomechanical characteristics of an internal fixation device with plantar plate fixation.

METHODS

Seven matched pairs of feet from human cadavers were used to compare the intramedullary (IM) device plus compression screw to plantar plate combined with a compression screw. Specimen constructs were loaded in a cyclic 4-point bending test. We obtained initial/final stiffness, maximum load, and number of cycles to failure. Bone mineral density was measured with peripheral quantitative computed tomography. Performance was compared using time to event analysis with number of cycles as time variable, and a proportional hazard model including shared frailty model fitted with treatment and bone mineral density as covariates.

RESULTS

On average the plates failed after 7517 cycles and a maximum load of 167 N, while the IM-implants failed on average after 2946 cycles and a maximum load of 69 N. In all pairs the 1 treated with IM-implant failed earlier than the 1 treated with a plate (hazard ratio for IM-implant versus plate was 79.9 (95% confidence interval [6.1, 1052.2], P = .0009). The initial stiffness was 131 N/mm for the plantar plate and 43.3 N/mm for the IM implant. Initial stiffness (r = .955) and final stiffness (r = .952) were strongly related to the number of cycles to failure. Bone mineral density had no effect on the number of cycles to failure.

CONCLUSION

Plantar plate fixation created a stronger and stiffer construct than IM fixation.

CLINICAL RELEVANCE

A stiffer construct can reduce the risk of nonunion and shorten the period of non-weight-bearing.

First tarsometatarsal joint derotational arthrodesis--a new operative technique for flexible hallux valgus without touching the first metatarsophalangeal joint

No operative technique for hallux valgus has been introduced in which the first metatarsophalangeal joint is not touched. We report the first tarsometatarsal joint derotational arthrodesis in which we mimic the function of the peroneus longus tendon without involving the first metatarsophalangeal joint, allowing function of the windlass mechanism without interference. We treated 66 patients (62 women and 4 men) with 84 flexible hallux valgus feet using our new operative technique. Preoperative and postoperative follow-up weightbearing radiographs were evaluated. Most patients had a pronation type foot (78%) preoperatively, and mean correction in hallux valgus and intermetatarsal angle was 20° and 9°, respectively (p < .001). The LaPorta classification showed a median change of 2.5 U (p < .001). We have described a new operative technique for flexible hallux valgus. The first tarsometatarsal joint derotational arthrodesis showed notable correction angles in hallux valgus, although the first metatarsophalangeal joint was left intact.

Tarsometatarsal/Lisfranc joint

Accurate early diagnosis with adequate reduction and maintenance of anatomic alignment of the dislocation or fracture within the Lisfranc joint complex have been found to be the key to successful outcomes regarding this injury. Because of the anatomic variations, the thin soft tissue envelop, and the abundance of ligamentous and capsular structures in the region, repair of these injuries can be a challenge. The classification systems used to describe these injuries aid in describing the mechanism of injury or displacement type present, which may aid in determining what treatment modality can provide the best outcome.

Surgical management and treatment algorithm for the subtle cavovarus foot

BACKGROUND

Subtle cavovarus foot is a condition that can lead to significant foot pain and disability. We review the results of our treatment algorithm at medium-term followup.

MATERIALS AND METHODS

Thirty-five consecutive patients with lateral based symptoms due to an underlying congenital subtle cavovarus foot type were surgically corrected. Various procedures were utilized, including some combination of the following: lateral displacement calcaneus osteotomy, peroneus longus to brevis transfer, dorsiflexion first metatarsal osteotomy, and Achilles tendon lengthening. Twenty-three patients, with 29 feet, returned for followup examination. The mean patient age at the time of surgery was 43.4 years, and the mean followup to date was 4.4 years.

RESULTS

The mean AOFAS ankle hindfoot score preoperatively was 45, and postoperatively was 90. Radiographically, the medial cuneiform to floor height changed from 3.5 cm preoperatively to 3.0 cm postoperatively. The talo-first metatarsal angle improved 7.5 degrees postoperatively. There were no nonunions. No patients to date have gone on to fusions or revisions. Ten feet (34%) required hardware removal. All patients had resolution of their symptoms following hardware removal.

CONCLUSION

The surgical management for the subtle cavovarus foot based on the proposed treatment algorithm provided symptomatic relief, longstanding correction, and high patient satisfaction.

Open reduction internal fixation versus primary arthrodesis for lisfranc injuries: a prospective randomized study

BACKGROUND

Dislocations and fracture-dislocations involving the tarsometatarsal joint are a relatively common injury. These injuries are associated with long-term disability from subsequent painful osteoarthritis and residual deformity. This study evaluated whether performing a primary arthrodesis (PA) resulted in improved functional outcome and fewer subsequent surgeries as compared to primary open reduction and internal fixation (PORIF).

MATERIALS AND METHODS

Forty patients with acute tarsometatarsal joint fractures or fracture dislocations were prospectively randomized to undergo either PORIF or PA. Clinical and radiographic examination, in addition to Short Form-36 (SF-36) and Short Musculoskeletal Function Assessment (SMFA) questionnaires, were evaluated at intervals of 3, 6, 12, and 24 months following surgery in 32 patients. A patient satisfaction phone survey was also performed.

RESULTS

The rate of planned and unplanned secondary surgeries, including hardware removal and salvage arthrodesis, between ORIF and PA groups, 78.6% vs. 16.7% was significantly different. No statistically significant differences were found with physical functioning for the PORIF or PA groups with regard to SF-36 or SMFA scores at any followup time interval. However, time from injury had a significant effect with impaired functioning at three months compared to all future intervals. No difference in satisfaction rates were found between PORIF and PA at an average of 53 months in a phone survey.

CONCLUSION

PA of tarsometatarsal joint injuries resulted in a significant reduction in the rate of followup surgical procedures if hardware removal is routinely performed with no significant difference in SF-36 and SMFA outcome scores when compared to PORIF.

The subtle cavus foot, "the underpronator"

Subtle cavus foot deformity is ubiquitous, yet it continues to be commonly missed. Simple physical examination maneuvers can provide information that allows well-planned nonoperative care and selection of operative procedures to correct the underlying cause as well as presenting pathology.

Triple arthrodesis in adults using rigid internal fixation: an assessment of outcome

The intermediate outcome of patients who underwent a triple arthrodesis for the treatment of adult foot disorders was evaluated with an outcome tool to determine if their pain and functional status were improved. We evaluated 63 feet in 57 patients who underwent a triple arthrodesis using rigid internal fixation for the treatment of hindfoot deformities associated with symptomatic arthrosis. Twenty-four men and thirty-three women, with an average age of 54 years, were evaluated. The average follow-up was 30 months. Multiple diagnoses contributed to hindfoot deformities with secondary arthrosis. Iliac crest bone graft was used in 56 of 63 cases (89%). Percutaneous heel cord lengthening was done in 53 of 63 cases (84%). Twenty-four of the thirty patients (80%) returned to work. Twenty-five patients were retired and two were unemployed before surgery. All patients except two (97%) were satisfied with the surgery and would have the surgery again. The average American Orthopaedic Foot and Ankle Society Ankle-Hindfoot preoperative score was 28 points, and the average postoperative score was 81 points (P < 0.0001). In the radiographic measurements, there was an average improvement of 12 degrees in the lateral talometatarsal angle, 7 degrees in the lateral talocalcaneal angle, and 10 degrees in the AP talometatarsal angle (P < 0.0001). Complications experienced included two varus malunions, two valgus malunions, two nonunions, two deep vein thromboses, one distal fibula stress fracture, and one wound infection. Of the 26 feet in 22 patients with mortise views available, 10 feet (38%) had evidence of ankle arthrosis and 19 feet (73%) had some degree of talar tilt postoperatively.

Report on the 1989 American Orthopaedic Foot and Ankle Society Fellow Scholarship

In 1989, the American Orthopaedic Foot and Ankle Society, Inc., sponsored a scholarship for a member to return to training to do a fellowship in foot and ankle surgery. The following is the account of Arthur Manoli, II, M.D., who served 3 months with Sigvard T. Hansen, Jr., M.D., at the Harborview Medical Center, University of Washington, Seattle, Washington, and 9 months with Marion C. Harper, M.D., at Vanderbilt University, Nashville, Tennessee.