Inadequate Purchase in the Proximal Tendon Stump Using the Percutaneous Achilles Repair System: A Technical Tip

Minimally invasive approaches for the Achilles tendon have emerged as viable alternatives for acute Achilles ruptures, with several potential benefits in comparison to the open approach. Occasionally, proper purchase in the proximal tendon stump is not achieved due to severe degenerative disease of the tendon. In this article, we present a technique in which a small accessory incision is used during percutaneous Achilles repair in order to pass the sutures in a more proximal and healthy area of the tendon. This technique is useful for situations in which adequate tendon grasp is not obtained, avoiding the need of conversion to an open approach.Level of Evidence: Level V: Expert opinion.

Long-Term Functional Outcomes and Return to Sport Activities in a Nonathlete Population after the Brostrom-Gould Repair

Category:

Sports; Trauma

Introduction/Purpose:

Acute ankle ligamentar lesion is one of the most common injuries related to sports practice and daily activities. Excellent clinical results have been achieved with functional rehabilitation in up to 80% of the patients. However, 20% may develop chronic ankle instability (CAI) with continued pain and repeated sprains, requiring surgical treatment. The aim of this study was to present the long-term functional outcomes and return to sport activities in a group of nonathlete patients with CAI who underwent lateral ligament repair using the Brostrom-Gould technique (BGT).

Methods:

Medical charts of 89 patients who underwent the BGT were retrospectively reviewed. The average follow-up was 7.1 (3.1 - 13.4) years. The mean age was 31.2 (16 - 65) years. 62 (69.7%) patients were male and 27 (30.3%), female. Demographic and clinical data were collected from medical records. For clinical and functional analysis, the AOFAS hindfoot-ankle score was applied (preoperatively and at the last follow-up) and return to physical activities was assessed. Other variables regarding residual pain, associated lesions (osteochondral lesions of the talus, bony or soft tissue impingements, syndesmotic and peroneal tendon injuries), associated predisposing anatomical conditions (tarsal coalition, cavovarus feet, accessory navicular bone and os trigonum), postoperative range of motion and complications were evaluated as well. Pre- and postoperative AOFAS scores were compared using paired Mann-Whitney test. Linear regression was used to assess the association of the Δ-AOFAS and return to physical activities with the other variables analyzed.

Results:

Prior to surgery, mean AOFAS score was 64.3, and postoperatively, 97.27 (p<.001). Seventy-one patients (79.8%) returned to the same physical activity. Associated lesions and pre-existing conditions were also treated (Tables 1-2). Complications occurred in 3 patients: posterior tibial nerve neuritis, hematoma at the calcaneal osteotomy site, paresthesia at the superficial peroneal nerve. Fifty-six (62.92%) patients had no complaints, 18 (20.22%) presented residual instability, 1 (1.12%) had eventual pain and 14 (15.73%) had constant mild pain. Partially limited inversion was found in 7 (7.87%) patients. In linear regression, residual instability and pre-existing conditions were related to Δ-AOFAS (p=.012 and p=.036). The first was associated with lesser improvement and the second with greater (Figure 1). Pain and residual instability were related to change in physical activity modality (Table 3).

Conclusion:

The present study demonstrated that patients who underwent the BGT presented excellent long-term functional outcomes with improvements in the AOFAS score. Approximately 80% returned to their previous level of physical activities. Those who underwent correction of a pre-existing anatomical condition in addition to the BGT were the ones who obtained the greatest improvements in AOFAS score. Eventual pain and residual instability after surgery were associated with limitations in physical activity.

Comparative Study of Patients Treated with the Original Lapidus Procedure That Evolved with and without Fusion Between the First and Second Metatarsals

Category:

Midfoot/Forefoot; Bunion

Introduction/Purpose:

The Original Lapidus procedure (OLP) consists of realigning the varus of the first metatarsal (M1) present in the hallux valgus (HV) deformities, by fusing the first tarsometatarsal joint (TMJ) and the M1 to the second metatarsal (M2). Compared to its modified version, some studies support that the OLP is more stable with less motion around the TMJ, which may prevent complications such as recurrence. However, fusion between M1 to M2 may not occur and its clinical and radiographic impact is still unknown. The aim of this study was to compare clinical, functional and radiographic outcomes in patients who underwent the OLP that evolved with and without fusion between the M1 and M2. Our null hypothesis was that they would have the same results.

Methods:

A retrospective and comparative study of twenty-nine patients (thirty-eight feet) with a mean follow-up of 18.03 (range, 6-51) months who underwent the OLP. They were divided in two different groups based on the presence of fusion and non-fusion between the M1 and M2 (Figure1). Twenty-three patients were included in the first group and fifteen in the second. Their average age was 48.74 (range,18-73) years. Twenty-five patients were female and four, male. Their mean body mass index (BMI) was 25.6 (range, 19.13-31.64). Clinical and functional data were assessed with the VAS for pain, AOFAS, LEFS and SF-12. SF- 12 comprises physical and mental health scales (PCS-12 and MCS-12). Radiographic parameters assessed were bony and soft tissue forefoot widths (BSFW), intermetatarsal-angle(IMA) and HV-angle(HVA). Intraclass Correlation Coefficients (ICC) were calculated for all radiographic measurements. Clinical, functional and radiographic measurements were compared between the two groups pre- and postoperatively using Student t Test.

Results:

The two groups were demographically similar in terms of mean age, BMI and follow-up time (p=.28, p=.84 and p=.06, respectively). Separately, patients from both groups presented significant improvements in all questionnaires (p<.001), except on MCS-12 (fusion p=.08 and non-fusion p=.27). Concerning radiographic parameters, they improved significantly in all measures (p<.001). When comparing the two groups, patients with fusion had higher scores only on the AOFAS questionnaire compared to those without (Table1). They improved from 37.61 preoperatively to 87.26 postoperatively and those without fusion improved from 44.47 to 82.80 (p<.05). Regarding radiographic parameters, there were no differences between both groups. They showed the same improvements on bony and soft tissue width, IMA and HVA (p=.09, p=16, p=.52 and p=.63, respectively), meaning that even when there is no fusion between M1 and M2, satisfactory radiographic corrections can be achieved (Table2). Pre- and postoperative ICC was good to excellent for most measurements (Table3).

Conclusion:

The present study showed that there was no difference in the amount of correction of HV deformities between patients who evolved with and without fusion between M1 and M2 after the OLP. However, patients with fusion may have better postoperative function when considering AOFAS scores. Further prospective and comparative studies with larger populations are required to assess the role of non-union between M1 and M2 in the outcomes of the OLP.

Effect of Forefoot Width Variation on Clinical and Functional Outcomes Following the Lapidus Procedure

Category:

Midfoot/Forefoot

Introduction/Purpose:

The Lapidus procedure (LP) is a powerful technique that often provides significant corrections of the hallux valgus (HV) deformities. In addition, it is described that forefoot width alters considerably with this technique, impacting in shoe wear. However, it has not yet been reported whether foot narrowing reflects on clinical and functional outcomes. This study aimed to evaluate the effect of variations in bony and soft tissue foot widths (BSFW) on clinical and functional outcomes after HV correction with the LP. Secondarily, we also tried to assess the relationship of standard radiographic measurements of HV with changes in BSFW.

Methods:

Forty-three feet in 35 patients with a mean follow-up of 18.5-months who underwent the LP were retrospectively reviewed. Bony width was measured from the most medial extent of the first metatarsal head to the most lateral extent of the fifth metatarsal head. Soft tissue width was measured considering the most medial and lateral shadow of the foot (Figure 1). Clinical and functional data were assessed with the VAS for pain, AOFAS, LEFS and SF-12. SF-12 comprises physical and mental health scales (PCS-12 and MCS-12). HV radiographic parameters as intermetatarsal-angle (IMA), HV-angle (HVA) and sesamoid- subluxation (SS) were assessed. Intraclass Correlation Coefficients (ICC) were calculated for BSFW. Clinical, functional and radiographic measurements were compared. Linear regression was used to assess the correlation of Δ-BSFW with clinical, functional and radiographic results. We also evaluated our sample at the cut-off point of quartile-50% to assess whether a given measure of Δ-BSFW was related to clinical and functional outcomes.

Results:

Pre- and postoperative ICC was 0.95 for bony and soft tissue width measurements. Bony width changed significantly from 95.5mm to 84.2mm (11.8%) and soft tissue width from 107.12mm to 100.84mm (5.86%) (p<.001 and p<.001). IMA, HVA and SS improved significantly. Significant clinical and functional improvements were observed, except in MCS-12. In simple linear regression, a correlation was found between variations of bony width with Δ-AOFAS and Δ-PCS-12, meaning that as the forefoot narrows, their values increase (p=.02 and p=.005). It was also related to Δ-IMA and Δ-SS, meaning that the forefoot narrows as these parameters improve (p<001 and p<0.001). Soft tissue width was related only to Δ-PCS-12 and Δ-IMA. In multiple linear regression, the strongest correlation observed was between bony width variation and Δ-IMA (P=.029,r2=0.22). At the quartile- 50%, in which our sample was divided equally, we have not found a given measure of Δ-BSFW that was significantly related to the clinical and functional questionnaires (Figure 2).

Conclusion:

The present study showed that narrowing of the forefoot after the LP improves clinical and functional outcomes, as measured by AOFAS and PCS-12. Besides, it also presented that correction of the radiographic parameters of the HV, mainly IMA, reflects on a significant decrease of the forefoot width. Further prospective and comparative studies with larger populations are required to evaluate the effects of forefoot width changes on clinical and functional outcomes.

Extensive Lesser Toes Plantar Plate Tears Reconstruction

Category:

Lesser Toes

Introduction/Purpose:

The plantar plate is a fibrocartilaginous structure that plays a fundamental role in the sagittal stability of the metatarsophalangeal joint (MTPJ). Traumatic and degenerative lesions affecting the plantar plate have the potential to cause instability, swelling, pain and deformity. Extensive plantar plate tears (grade IV) still challenge surgeons as primary repair is impossible, demanding a reconstructive procedure which, unfortunately, can be associated with high morbidity such as stiffness, persistence of discomfort, vascular compromise to the digit and amputation. The purpose of this work is to describe a new technique that uses a synthetic tape and one absorbable screw to achieve the MTPJ stabilization in plantar plate grade IV tears. We believe that this procedure can achieve better results than other techniques described in the literature.

Methods:

Two bone tunnels are made at the base of the proximal phalanx. Both medial and lateral tunnels are directed in a light oblique fashion from a distal-dorsal entry point to a proximal, justarticular plantar exit. Two new oblique dorsal-plantar bone tunnels - medial and lateral - are made at the distal metaphyseal metatarsal area. A #2 FiberTape is passed through the bone tunnels guided by a Nitinol wire, creating a mesh for the plantar stabilization of the MTPJ. Then both Fiber Tapes limbs are driven, with the help of a nitinol loop, through the plantar orifices of corresponding sides of the metatarsal bone tunnels, exiting in its dorsal aspect. One of the limbs of the tape is passed from dorsal to plantar trough the other metatarsal orifice. Both limbs are tensioned, and the toe should be kept at neutral sagittal position (flexion-extension). Fixation is made with a Biotenodesis screw.

Results:

Only a few patients were submitted to this technique. At one year follow up, none of them presented with complaints or complications.

Conclusion:

The surgical technique described in this article can change the way physicians treat plantar complex plantar plate tears when there is no viable biologic tissue to repair. A lesser complication rate it's also expected. Nonetheless comparative, and biomechanical studies are still needed to confirm our hypothesis.

Arthroscopic Syndesmotic Repair with Suture Tape Augmentation

Category:

Arthroscopy; Ankle; Sports

Introduction/Purpose:

High ankle sprains or syndesmotic lesions can occur after an external rotation force in a dorsiflexed foot. These lesions may present isolated or combined with medial collateral ligaments lesions or fractures. Unstable lesions should be operatively treated since syndesmotic instability can cause pain, disability, chondral lesions and arthritis. A recent biomechanical cadaveric study suggested that syndesmosis suture button fixation with suture tape augmentation can restore stability to a pre injury level, while suture button alone was insufficient to restore stability and screw fixation was associated with overtightening of the syndesmosis. The purpose of this work is to describe a new minimally invasive arthroscopic technique that uses a synthetic tape to augment suture button fixation of syndesmotic instability.

Methods:

After arthroscopic debridement of the syndesmosis, one bone tunnel is made with a 4.0mm drill at the anterolateral distal tibia rim and at the anterior distal fibula just above the anterior talofibular ligament origin. A 4,75mm swivelock armed with a fibertape (Arthrex©) is introduced at the distal fibula hole. After obtaining adequate syndesmotic reduction with the help of a reduction clamp, suture button fixation was made through a mini lateral access. The fibertape was then appropriately tensioned and inserted at the distal tibia hole with another 4,75mm swivelock. Adequate reduction was observed with the Mercedes-Benz sign and stability was confirmed arthroscopically.

Results:

Only a few patients were submitted to this technique. At short follow up, none of them presented with complications or complaints

Conclusion:

We believe that unstable syndesmotic treatment using the suture button fixation and anterior inferior tibiofibular arthroscopic augmentation with suture-tape described in this work can restore syndesmotic stability to pre injury levels with low morbidity and lesser complication rates compared to other techniques. Nonetheless, comparative clinical studies are still needed to confirm our hypothesis.

Osteochondral Lesions of the Tibial Plafond and Ankle Instability With Ankle Cartilage Lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

An international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to present the consensus statements on osteochondral lesions of the tibial plafond (OLTP) and on ankle instability with ankle cartilage lesions developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle.

METHODS

Forty-three experts in cartilage repair of the ankle were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 4 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held.

RESULTS

A total of 11 statements on OLTP reached consensus. Four achieved unanimous support and 7 reached strong consensus (greater than 75% agreement). A total of 8 statements on ankle instability with ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, and seven reached strong consensus (greater than 75% agreement).

CONCLUSION

These consensus statements may assist clinicians in the management of these difficult clinical pathologies.

LEVEL OF EVIDENCE

Level V, mechanism-based reasoning.

Scaffold-Based Therapies: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Scaffold-Based Therapies" developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle.

METHODS

Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%.

RESULTS

A total of 9 statements on scaffold-based therapies reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, 8 reached strong consensus (greater than 75% agreement), and 1 was removed because of redundancy in the information provided. All statements reached at least 80% agreement.

CONCLUSIONS

This international consensus derived from leaders in the field will assist clinicians with applying scaffold-based therapies as a treatment strategy for osteochondral lesions of the talus.

LEVEL OF EVIDENCE

Level V, expert opinion.

Osteochondral Autograft: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

Treatment guidelines for cartilage lesions of the talus have been based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions on key topics regarding cartilage lesions of the talus. The purpose of this consensus article is to explain the process and delineate the consensus statements derived from this consensus meeting on the use of "osteochondral autograft" for osteochondral lesions of the talus.

METHODS

Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; and unanimous, 100%.

RESULTS

A total of 14 statements on osteochondral autograft reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Two achieved unanimous support, 11 reached strong consensus (greater than 75% agreement), and 1 achieved consensus. All statements reached at least 67% agreement.

CONCLUSIONS

This international consensus derived from leaders in the field will assist clinicians with osteochondral autograft as a treatment strategy for osteochondral lesions of the talus.

The Effect of Different Bone Marrow Stimulation Techniques on Human Talar Subchondral Bone: A Micro-Computed Tomography Evaluation

PURPOSE

To evaluate morphological alterations, microarchitectural disturbances, and the extent of bone marrow access to the subchondral bone marrow compartment using micro-computed tomography analysis in different bone marrow stimulation (BMS) techniques.

METHODS

Nine zones in a 3 × 3 grid pattern were assigned to 5 cadaveric talar dome articular surfaces. A 1.00-mm microfracture awl (s.MFX), a 2.00-mm standard microfracture awl (l.MFX), or a 1.25-mm Kirschner wire (K-wire) drill hole was used to penetrate the subchondral bone in each grid zone. Subchondral bone holes and adjacent tissue areas were assessed by micro-computed tomography to analyze adjacent bone area destruction and communicating channels to the bone marrow. Grades 1 to 3 were assigned, where 1 = minimal compression/sclerosis; 2 = moderate compression/sclerosis; 3 = severe compression/sclerosis. Bone volume/total tissue volume, bone surface area/bone volume, trabecular thickness, and trabecular number were calculated in the region of interest.

RESULTS

Visual assessment revealed that the s.MFX had significantly more grade 1 holes (P < .001) and that the l.MFX had significantly more poor/grade 3 holes (P = .002). Bone marrow channel assessment showed a statistically significant increase in the number of channels in the s.MFX when compared with both K-wire and l.MFX holes (P < .001). Bone volume fraction for the s.MFX was significantly less than that of the l.MFX (P = .029).

CONCLUSIONS

BMS techniques using instruments with larger diameters resulted in increased trabecular compaction and sclerosis in areas adjacent to the defect. K-wire and l.MFX techniques resulted in less open communicating bone marrow channels, denoting a reduction in bone marrow access. The results of this study indicate that BMS using larger diameter devices results in greater microarchitecture disturbances.

CLINICAL RELEVANCE

The current study suggests that the choice of a BMS technique should be carefully considered as the results indicate that smaller diameter hole sizes may diminish the amount of microarchitectural disturbances in the subchondral bone.

Functional Outcomes of Tibialis Posterior Tendoscopy With Comparison to Magnetic Resonance Imaging

BACKGROUND

The purpose of the current study was to report functional outcomes of tendoscopy for treatment of tibialis posterior tendon pathology as well as compare its diagnostic capability with magnetic resonance imaging (MRI).

METHODS

Clinical records and MRI of 12 patients who underwent tendoscopy of the tibialis posterior tendon (TPT) were retrospectively reviewed. Mean follow-up was 31 months (range, 26-43 months). Preoperative MRI findings were compared with tendoscopic findings to assess the diagnostic agreement between each modality. Functional outcomes were assessed using the Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) General Health Questionnaire pre- and postoperatively. Mean patient age was 43 years (range, 17-63 years). Mean duration of preoperative symptoms was 15.5 months (range, 3-36 months).

RESULTS

Pathologies addressed via tendoscopy included tenosynovitis, tendinosis, stenosis, tendon subluxation, and partial thickness tear (via mini-arthrotomy). Preoperative MRI findings were in agreement with tendoscopic findings in 8 of 12 cases (67%). Tendoscopy diagnosed and allowed access for treating pathology that was missed on MRI in the remaining four cases. The FAOS improved from a mean preoperative score of 58 (range, 36-78) to a mean postoperative score of 81 (range, 44-98) (P < .01). The SF-12 score improved from a mean preoperative score of 34 (range, 13-51) to a mean postoperative score of 51 (range, 21-76) (P = .01).

CONCLUSIONS

Although MRI is considered an effective imaging technique for tendon pathology, tendoscopy may be a more sensitive diagnostic tool. Tendoscopy was an effective minimally invasive tool to diagnose and treat tibialis posterior tendon pathology resulting in functional improvements in the short-term for early stage TPT dysfunction. Further studies comparing tendoscopy with traditional open approaches are warranted.

LEVEL OF EVIDENCE

Level IV case series.