Foot & Ankle International

Osteochondral lesions of the talus (OLT) are relatively uncommon but may be a cause of significant pain and disability. Although the majority of patients have an osteochondral lesion of the talus that is unilateral, bilateral involvement has been reported in 10% to 25% of cases. In addition, factors that cause one side to be symptomatic and the contralateral side to be asymptomatic have never been evaluated.

A database containing all patients at our institution with an OLT has been maintained for the past 23 years. This was reviewed and patients with bilateral involvement identified. A chart review was performed to determine location and size of the OLT, which were symptomatic, associated with trauma, and required surgery.

Between 1984 and 2007, 526 patients with an OLT were seen. Fifty-two patients had bilateral OLT, for an overall bilateral incidence of 10%. Of these, 16 patients required no surgery (Group 1), 31 required only unilateral surgery (Group 2), and five required bilateral surgery (Group 3). 88% of the OLT were located medially. Symptomatic talar lesions were significantly larger compared to asymptomatic OLT (p < 0.01). Of those that required only unilateral surgery, the size of the OLT eventually requiring surgery was significantly larger (p < 0.01).

The overall incidence of bilateral involvement was 10%. A majority of patients with bilateral involvement had the OLT located on the medial side. A larger surface area appeared to be related to the presence of symptoms and the need for surgery.

The goal of this review was to compare the functional outcomes of patients less than 60 and greater than or equal to 60 years old following operative stabilization of unstable ankle fractures. The review was conducted as a retrospective analysis of prospectively collected data at two level one trauma centers and a tertiary referral academic center.

All patients operatively treated for an unstable ankle fracture were entered into a database and prospectively followed. The postoperative protocol was standardized for all patients. Baseline characteristics, complications, additional surgery, functional status and the American Orthopaedic Foot and Ankle Society score (AOFAS) were assessed. The intervention chosen was open reduction and internal fixation of unstable ankle fractures. AOFAS hindfoot score and Short Musculoskeletal Functional Assessment (SMFA) questionnaire were used as the main outcome measures in the study. A p < 0.05 was considered significant.

Three hundred sixty-nine (369) patients were entered into the database, 313 (84.8%) were less than 60 years old. At 3 months, 57% (32/56) of patients greater than or equal to 60 years old reported limitation of activities versus 33% (103/313) of patients less than 60 years old (p = 0.005). At 6 and 12 months, these percentages improved to 41% versus 10% (p = 0.001), and 29% versus 7.4% (p = 0.001) for older and younger individuals respectively. However, when compared to their baseline scores, both groups achieved a return to pre-injury status. Total AOFAS scores were not significantly different at 3, 6, or 12 months (p = 0.431).

Operative fixation of unstable ankle fractures in patients greater than or equal to 60 years old can provide a reasonable functional result at the 1-year followup with a return to preoperative baseline even though they report more limitation of activities than younger patients.

Knowledge of joint kinematics in the healthy and diseased joint may be useful if surgical techniques and joint replacement designs are to be improved. To date, little is known about the kinematics of the arthritic tibiotalar joint and its effect on the kinematics of the subtalar joint.

Kinematics of the ankle joint complex (AJC) were measured in six patients with unilateral post-traumatic tibiotalar osteoarthritis in simulated heel strike, midstance and toe off weight bearing positions using magnetic resonance and dual fluoroscopic imaging techniques. The kinematic data obtained was compared to a normal cohort from a previous study.

From heel strike to midstance, the arthritic tibiotalar joint demonstrated 2.2 ± 5.0 degrees of dorsiflexion while in the healthy controls the tibiotalar joint plantarflexed 9.1 ± 5.3 degrees (p < 0.01). From midstance to toe off, the subtalar joint in the arthritic group dorsiflexed 3.3 ± 4.1 degrees whereas in the control group the subtalar joint plantarflexed 8.5 ± 2.9 degrees (p < 0.01). The subtalar joint in the arthritic group rotated externally 1.2 ± 1.0 degrees and everted 3.3 ± 6.1 degrees from midstance to toe off while in the control group 12.3 ± 8.3 degrees of internal rotation and 10.7 ± 3.8 degrees eversion (p < 0.01 and p < 0.01, respectively) was measured.

The current study suggests that during the stance phase of gait, subtalar joint motion in the sagittal, coronal, and transverse rotational planes tends to occur in an opposite direction in subjects with tibiotalar osteoarthritis when compared to normal ankle controls. This effectively represents a breakdown in the normal motion coupling seen in healthy ankle joints.

Knowledge of ankle kinematics of arthritic joints may be helpful when designing prostheses or in assessing the results of treatment interventions.

It has been reported that the operative outcome of tarsal tunnel syndrome caused by space-occupying lesions is more favorable than those caused by other reasons. The purpose of this clinical study was to report our clinical results after surgical treatment for tarsal tunnel syndrome caused by benign space-occupying lesions.

From July 2004 to February 2007, 20 patients underwent surgical decompression for tarsal tunnel syndrome in our institution. Out of them, 13 cases were due to space-occupying lesions around the tarsal tunnel. The average age was 51.3 and the mean symptom duration was 16.5 months. The operation included complete release of the tarsal tunnel and removal of the space-occupying lesion. The clinical outcomes measured were a pain visual analogue scale (VAS), AOFAS score and the degree of subjective satisfaction.

Ganglion was the most frequent cause (10 cases). Other pathologies included synovial chondromatosis, a Schwannoma and a talocalcaneal coalition. There was a significant improvement after surgery in term of VAS (6.4/2.2) and AOFAS score (77.8/92.7). Seven of 13 were satisfied with the results, three felt they had a fair result, and three were dissatisfied.

Though significant improvement was found in the average VAS and AOFAS score, subjective satisfaction was less favorable (54%) than expected. We believe surgeons should be more cautious concerning outcomes when expectations of surgery are discussed with patients.

Level of Evidence: IV, Retrospective Case Study

The incidence of non union following a first tarsometatarsal arthrodesis (Lapidus procedure) has decreased significantly with modern techniques of minimal bone resection, meticulous bone surface preparation and rigid internal fixation. We evaluated whether a postoperative wedge shoe would increase our non-union rate.

Nineteen adult female patients (27 feet; eight bilateral, five simultaneous) undergoing a first tarsometatarsal arthrodesis for hallux valgus associated with a hypermobile first ray or for recurrent hallux valgus were managed postoperatively by allowing them to bear weight in a wedge shoe instead of a cast. Radiographs were evaluated for signs of fusion.

All 27 feet went on to successful union after 6 to 24 weeks. There was one superficial wound infection and one case of recurrence of the hallux valgus.

Based on our results, we allow adult patients undergoing a Lapidus type procedure to be managed in a postoperative wedge shoe.

First metatarsalphalangeal joint (MTPJ) arthrodesis is a commonly performed procedure for the treatment of a variety of conditions affecting the hallux. There are several different methods to accomplish the fusion. We utilized a method incorporating a ball and cup preparation of the joint, followed by stabilization of the arthrodesis site utilizing the Accutrak congruent first MTPJ fusion set.

We prospectively evaluated two hundred consecutive patients who underwent first MTPJ arthrodeses utilizing the Accutrak congruent first MTPJ fusion set. Patients were evaluated preoperatively, postoperatively, and at a final followup, utilizing the AOFAS forefoot scoring system.

Two hundred consecutive patients underwent first MTPJ arthrodeses by the same surgeon. All but three feet (230/233) (98.7%) went on to solidly fuse. Three of the patients did not fuse solidly. One patient broke two of the screws, and the other two patients did not have hardware failure. All patients dramatically improved their AOFAS scores compared with pre-surgical values. There were three minor hardware problems in the group of patients who solidly fused their joint.

We concluded that a solid first MTPJ fusion results in excellent function and pain relief. The Accutrak first MTPJ fusion system would appear to be an ideal implant system to accomplish a fusion because of its low profile, strength, and ease of use. Compared to other methods we have used, this procedure results in a very high rate of fusion, with minimal complications and excellent patient satisfaction.

Closed tibialis anterior tendon rupture is an uncommon condition typically occurring in the middle aged to elderly patient. Diagnosis may be delayed due to unfamiliarity with the problem by the treating physician.

We treated seven patients (4 males aged 54 to 80; 3 females aged 43 to 82) with this problem. Four patients had a history of systemic corticosteroid use and one had had a local steroid injection. Four of the seven patients were managed with direct operative repair and one with a non-anatomical repair to the talar neck. Two patients were managed nonoperatively of whom one subsequently required late surgical reconstruction. Patients were reviewed clinically and completed a Foot and Ankle Outcome Score (FAOS). Followup ranged from 12 months to 12 years.

In the operative group four patients had no functional limitations from the injury and one had mild ankle weakness. One in the nonoperative group required salvage surgery four years after rupture. At followup the mean FAOS was 85 (range, 64 to 98) in the operative group and 52 (range, 28 to 75) in the nonoperative group.

A ruptured tibialis anterior tendon is a rare condition. There is an association with systemic steroid use as well as local steroid injection. Early diagnosis allows operative repair by various techniques leading to predictably good results. Our experience supports operative repair even in the elderly patient.

Level of Evidence: IV, Retrospective Case Series

Anecdotal evidence suggests that specimens submitted for histopathologic assessment during hallux valgus surgery most commonly reveal degenerative changes. The purpose of this study was to evaluate the cost effectiveness of routine examination of tissue from hallux valgus procedures. We hypothesized that such examination rarely diagnoses a new condition and does not alter postoperative management.

Specimens from 315 consecutive primary hallux valgus reconstructions performed between November 1995 and August 2002 were retrospectively analyzed. Patient charts were reviewed to determine the number of cases in which new diagnoses were made or treatment altered based upon histopathologic examination. Cost effectiveness was assessed by identifying the reimbursement for professional fees charged for these analyses. The total reimbursement per new diagnosis made and per alteration of treatment were calculated.

Degenerative changes were diagnosed in the majority of speciments (97.5%, 307 of 315). Other diagnoses included rheumatoid arthritis (1.3%, four of 315), gouty arthritis (1.0%, three of 315), and pseudogout (0.3%, one of 315). A new diagnosis was made only in the one patient (0.3%, one of 315) with pseudogout. Postoperative management was unchanged in every case.

Routine submission of specimens obtained during hallux valgus surgery is not cost effective. New diagnoses are very rare and postoperative management did not change.

Level of Evidence: IV, Retrospective Case Series

One of the more serious diabetic complications is Charcot neuroarthropathy (CN), a disease that results in arch collapse and permanent foot deformity. However, very little is known about the etiology of CN. From a mechanical standpoint, it is likely that there is a “vicious circle” in terms of (i) arch collapse causing increased midfoot joint pressures, and (ii) increased joint contact pressures exacerbating the collapse of midfoot bones. This study focused on assessment of peak joint pressure difference between diabetic and non-diabetic cadaver feet during simulated walking. We hypothesized that joint pressures are higher for diabetics than normal population.

Sixteen cadaver foot specimens (eight control and eight diabetic specimens) were used in this study. Human gait at 25% of typical walking speed (averaged stance duration of 3.2s) was simulated by a custom-designed Universal Musculoskeletal Simulator. Four medial midfoot joint pressures (the first metatarsocuneiform, the medial naviculocuneiform, the middle naviculocuneiform, and the first intercuneiform) were measured dynamically during full stance.

The pressures in each of the four measured midfoot joints were significantly greater in the diabetic feet (p = 0.015, p = 0.025, p < 0.001, and p = 0.545, respectively).

Across all four tested joints, the diabetic cadaver specimens had, on average, 46% higher peak pressures than the control cadaver feet during the simulated stance phase.

This finding suggests that diabetic patients could be predisposed to arch collapse even before there are visible signs of bone or joint abnormalities.

While incorrect length of a fibular fracture reduction can be measured by plain radiographs, accurate imaging of rotational deformities requires computed tomography (CT). Operative correction of fibular malrotation has not been accurately measured. The aim of this study was to evaluate the accuracy of operative correction of fibular malrotation.

Six pairs of formalin-fixed, lower leg cadaver specimens had shortening with additional internal or external rotation induced by segmental fibular resection and plate fixation. The deformity was measured by CT. Two experienced surgeons performed standardized corrective operations on six specimens each. The postoperative results were measured by CT.

The mean overall accuracy for correction of malrotation was 1.58 degrees (SD = 0.8 degrees). There were no significant differences between the two surgeons performing the corrections.

The accuracy of operative correction of malrotation in this cadaver model is in accordance with the requirements reported in clinical studies.

Considering the error margin for CT analysis, correction within 5 to 10 degrees seems practical.

Tendo-Achilles lengthening (TAL) and gastrocnemius recession (GR) are components of the operative treatment for certain foot conditions. We investigated changes in rabbit gastrocsoleus weight, volume, and percent fat resulting from TAL, GR, and immobilization.

Eighteen rabbits were randomized into three groups. Group I = gastrocnemius recession; Group II = (TAL) Z-plasty lengthening; Group III = immobilization only. Treatment limbs were randomized. Six randomly selected contralateral limbs were used for controls. At 12 weeks the gastrocnemius and soleus were weighed (g) and measured (ml) separately. Values were combined and analyzed as a gastrocsoleus complex. The weight, volume, and percentage of fatty infiltration were analyzed using one-way analysis of variance (ANOVA).

The following differences were statistically significant. GR volume was less than control (p < 0.01); TAL weight and volume was less than control (p < 0.01); GR percent fat was greater than control (p < 0.05) and TAL percent fat was greater than control (p < 0.05). GR weight and volume was less than cast only (p < 0.01); TAL weight and volume was less than cast only (p < 0.01); TAL percent fat was greater than cast only (p < 0.01); GR percent fat was greater than cast only (p < 0.05); GR weight was greater than TAL (p < 0.05).

In a rabbit model, the findings suggest the gastrocsoleus undergoes atrophy and fatty infiltration after TAL or GR. Immobilization does not contribute to either process.

These findings correlate with human functional studies documenting the relationship between TAL or GR and decrease in plantarflexion strength. Further studies are needed to determine if significant variation in functional differences due to TAL versus GR exists.