Faculty Bibliography

Several methods of obtaining ankle fusion have been described, with numerous studies reporting on patient populations with varied diagnoses and various methods of fixation. This has led to outcome analyses that are difficult to interpret. Our hypothesis is that using a standard method of fusion, without the aid of allograft, a solid ankle fusion can be achieved in patients with end-stage ankle arthritis, and that this outcome can be reflected in standardized outcome tools. Forty-one consecutive ankle fusions in 40 patients were included in our study, with a minimum followup of 3 years. All patients had an ankle arthrodesis using two parallel retrograde 7.3-mm screws and local fibular graft. All but two patients obtained a solid talocrural union (95%), with a mean postoperative improvement in the American Orthopaedic Foot and Ankle Society score of 23 points. Results of our study showed that a simple technique based on sound mechanical and biologic principles can yield excellent outcomes for patients.

BACKGROUND:Ankle arthrodesis remains the benchmark of treatment for end-stage arthrosis of the ankle joint. Despite that, the incidence of nonunion can be as high as 15%. Various strategies have been used to reduce the incidence of nonunion, including multiple compression screws and larger diameter screws to improve mechanical stability and compression. The space occupied by an increasing amount of hardware across a finite surface area available for fusion has prompted concern that this strategy may be counterproductive and may reduce the biological potential of the construct. The purpose of this study was to look at 40 anatomic sawbone specimens of the ankle to determine the amount of talar surface contact area used by the screw fixation during arthrodesis. METHODS:Four groups were created to examine different techniques for arthrodesis. Simulated ankle arthrodeses were done using two- or three-screw fixation with 6.5-mm and 7.3-mm screws. Hardware was subsequently removed and the surface area used by the passing screws was measured. Total surface areas were calculated for each of the 40 specimens. RESULTS:The maximal surface area of the talus occupied by screws occurred when using three 7.3-mm screws. This configuration used 16% of the possible talar surface area available for arthrodesis. CONCLUSION/CONCLUSIONS:The use of additional screw fixation when performing an ankle arthrodesis does not sacrifice a major amount of the tibiotalar contact area and will most likely not affect the biologic environment needed to obtain fusion.

UNLABELLED:Interposition arthroplasty reportedly improves outcomes after traditional salvage procedures for advanced hallux rigidus. We hypothesized this procedure can provide pain relief and satisfactory function with few complications. We examined 18 patients with severe articular cartilage loss who received 21 interposition arthroplasties. The patients a mean age was 56 years. They had a mean followup of 38 months. All patients had substantial loss of articular cartilage when examined intraoperatively. Patients were evaluated using the American Orthopaedic Foot and Ankle Society and Short Form-36 scores. All 18 patients had pain relief, and 17 of 18 patients said they would have the procedure again. The mean postoperative increase in range of motion of the first meta-tarsophalangeal joint was 37 degrees . The mean American Orthopaedic Foot and Ankle Society and Short Form-36 scores were 78.4 and 96.3, respectively. The complication rate was 6%. Results of our study indicate that interposition arthroplasty relieves pain and restores motion in patients with advanced hallux rigidus and may offer a reliable option to fusing the joint. LEVEL OF EVIDENCE/METHODS:Therapeutic study, Level IV (case series).

Metatarsalgia of the central ray is a major surgical challenge. Without precise correction, transfer lesions may occur at an adjacent metatarsal or patients may have inadequate pain relief. Current surgical treatment strategies do not facilitate precise positioning in different planes, resulting in disappointing outcomes. To achieve better outcomes we used an oblique sliding osteotomy to facilitate precise correction. We hypothesized the procedure would reduce pain in patients with prominent second and/or third metatarsal heads, with few complications. We retrospectively reviewed 32 consecutive patients with 42 osteotomies of the lesser metatarsal bones. The mean and median ages at the time of surgery were 49 and 54 years, respectively, with a minimum followup of 26 months. Thirty-one patients (97%) had relief of plantar pain. The mean American Orthopaedic Foot and Ankle Society score was 82.4 points. We identified no transfer lesions. The median time to radiographic union was 10 weeks. Although time to bony union can be extended, the oblique sliding osteotomy facilitates intraoperative adjustment to provide the precise positioning critical to eliminating plantar pain.

Isolated carpal scaphoid dislocations are rare. Because of this, treatment strategies can be conflicting and vague. The current authors present a case of isolated scaphoid dislocation that was treated initially with closed reduction and percutaneous pinning. Failure of this index treatment necessitated open reduction and internal fixation providing an adequate short-term outcome. Current treatment strategies now advocate ligament reconstruction as a first-line treatment to restore normal anatomy and preserve function.

BACKGROUND:Patellar complications following endoprosthetic reconstruction can occur as a result of anatomic, physiologic, and surgical reasons. Patellar impingement on tibial polyethylene is a complication of distal femoral replacement, and it is frequently related to inaccurate restoration of the joint line and to soft-tissue contracture. The purpose of our study was to determine the prevalence and type of patellar complications following distal femoral replacements after excisions of bone tumors. METHODS:The results of reconstruction with use of a rotating-hinge endoprosthesis following excision of a distal femoral tumor in forty-three patients were retrospectively reviewed. Patients were followed clinically and radiographically for a minimum of forty-eight months or until death. Pain status, functional scores, and the range of motion were determined from a prospectively maintained database. The ratio of the patellar tendon length to the height of the patellar tendon insertion, as described by Insall and Salvati, was calculated. In addition, we attempted to determine whether the position of the patella was associated with anterior knee pain or with the functional scores derived with use of the International Society of Limb Salvage (ISOLS) scoring system. RESULTS:Thirty-five patellar complications, including eleven cases of impingement, occurred in twenty-seven patients (63%). We found no difference, on the basis of our sample size, with regard to the presence of patellar pain, the range of motion, or the Insall-Salvati ratio between the patients with and those without impingement. The ratio of the patellar tendon length to the height of the patellar tendon insertion averaged 0.9 in the group with impingement and 1.4 in the group without impingement (p = 0.07). The ISOLS score averaged 21.2 points in the group with impingement compared with 24.2 points in the group without impingement (p = 0.01). Patella baja occurred in nine patients. The average ISOLS score (and standard deviation) was 20.1 +/- 4.4 points for the patients with patella baja compared with 24.8 +/- 3.9 points in the group with a normal patellar position (p = 0.004). Patellar fracture occurred in two patients, and osteonecrosis occurred in two patients. These patients were treated nonoperatively. CONCLUSIONS:Patellar complications are common after distal femoral resection and endoprosthetic reconstruction. Patellar impingement on the polyethylene tibial bearing surface is a more common and important complication of distal femoral replacement than has been reported to date. Patella baja is also a relatively common complication, which has a negative impact on knee function.

BACKGROUND:Operative strategies used in resecting the digital nerve in Morton neuroma emphasize retaining the digital artery. Concern over inadvertent resection of the digital vessel has prompted many surgeons to avoid adjacent interdigital neurectomies when more than one nerve is affected. METHODS:The current study examined 674 consecutive pathologic specimens obtained after neurectomy. RESULTS:The digital vessel was identified along with the resected nerve in 39% of specimens. No adverse effect was recorded from these arterial resections. CONCLUSION/CONCLUSIONS:Extensive collateralization of digital vessels is hypothesized to account for the lack of adverse sequelae.

Calcaneal ostectomy is the benchmark for definitive surgical treatment in patients with Haglund's syndrome, despite conflicting and unpredictable study results. The current study's hypothesis is that when adequate bone is resected and outcomes are evaluated using validated scores, calcaneal ostectomy can give reliable and predictable results. Thirty six consecutive patients (39 feet) underwent calcaneal ostectomy for Haglund's deformity between 1998 and 2002. All patients were evaluated with the AOFAS score and SF-36v2 questionnaire. The mean time to follow-up was 51 months. The mean AOFAS score following surgery was 86/100 points; the mean SF-36v2 score following surgery was 144/152. Six of the 36 patients interviewed, however, would not recommend the procedure to others, citing mainly prolonged recovery time. Calcaneal ostectomy achieves good-to-excellent results in the treatment of Haglund's deformity when appropriate amounts of bone are excised. However, patients must be made aware of the necessary time to recovery, between 6 months and 2 years.