Foot & Ankle Orthopaedics最新文献

Background: The Zadek osteotomy, a dorsal closing-wedge procedure of the calcaneus, is commonly used in the surgical treatment of insertional Achilles tendinopathy, particularly in patients unresponsive to conservative measures. Although minimally invasive surgical (MIS) techniques offer potential benefits such as reduced soft tissue trauma and faster recovery, concerns persist regarding the risk of iatrogenic injury to the sural nerve because of limited visualization. This cadaveric study aims to provide a detailed anatomical assessment of the sural nerve and its branches in relation to the entry point of the MIS Zadek osteotomy, with the goal of quantifying their proximity and offering data that may help reduce the risk of nerve injury during the procedure.

Methods: Twenty fresh-frozen human lower limb specimens were subjected to a standardized MIS Zadek osteotomy using a 3 × 30-mm Shannon burr. The osteotomy was guided fluoroscopically and performed through a lateral percutaneous approach. Post-procedure, meticulous anatomical dissections were conducted to identify the sural nerve and measure its distance from the anterior and posterior arms of the osteotomy using digital calipers with 0.1-mm precision. Measurements were independently recorded by 2 observers to ensure accuracy.

Results: The sural nerve was successfully identified in all specimens. No instances of sural nerve transection or gross anatomical disruption were observed. The mean distance from the osteotomy to the sural nerve was 11.95 mm, with a range of 8.3 to 15.4 mm and an SD of 2.18 mm. These findings suggest that when performed within the defined anatomical parameters, the MIS Zadek osteotomy maintains a safe distance from the sural nerve.

Conclusion: In our cadaver study, we found that the MIS Zadek osteotomy maintained a mean distance of 11.95 mm from the sural nerve. These findings define anatomical proximity; clinical safety requires prospective validation.

Clinical relevance: Our study defines a reproducible anatomical margin for MIS Zadek osteotomy; clinical safety needs prospective validation.

Graphical Abstract.

Background: First metatarsophalangeal (MTP) joint fusion is a common surgical procedure to treat hallux rigidus and malalignment at the MTP joint. Nonunion after first MTP arthrodesis can cause continued pain and limitation in function. The present study aims to provide a single-site analysis of nonunion risk factors after first MTP fusion. We hypothesized that diabetes, smoking, and a body mass index (BMI) ≥30 are associated with increased risk of nonunion.

Methods: This is a retrospective cohort study. All patients who underwent first MTP fusion performed by 3 orthopaedic foot and ankle surgeons between September 20, 2013, and September 20, 2023, were included. Patient demographics, comorbidities, intraoperative medications, and postoperative complications were collected. Relationships to nonunion were evaluated using the multivariable logistic regression (a < 0.05) and both odds ratio (OR) and adjusted odds ratio (aOR) were calculated.

Results: A total of 417 patients (450 feet) were included. Average BMI was 27.94 ± 6.79. There were 25 nonunions, which did not statistically differ in sex or age. Per-patient models identified idiopathic peripheral neuropathy and bilateral surgeries as independent predictors, with BMI ≥30 showing a trend toward significance. Diagnosis of peripheral neuropathy was subdivided into diabetic and idiopathic peripheral neuropathy, with increased nonunion rates in the idiopathic group. Osteoporosis, bisphosphonate use, and smoking history showed no statistical difference in nonunion rates. BMI and diabetes showed statistical differences with univariate logistic regression but were deemed insignificant on multivariate analysis.

Conclusion: In this single-institution cohort, idiopathic peripheral neuropathy and bilateral MTP fusions were associated with higher odds of nonunion; findings for BMI ≥30 and diabetes should be interpreted prudently, given the limited events and wide CIs.

Level of evidence: Level III, retrospective cohort study.

Background: First tarsometatarsal (TMT) arthrodesis is a surgical option for moderate to severe hallux valgus, particularly in the setting of first-ray instability. The use of a supplemental intermetatarsal screw (IMS) has emerged as a technique intended to enhance transverse plane stability and may help maintain correction; however, limited clinical data exist regarding its radiographic and complication profile. This study compared radiographic correction, maintenance of alignment, and postoperative complications following TMT arthrodesis with vs without IMS fixation.

Methods: A retrospective review was performed of adult patients who underwent first TMT arthrodesis for hallux valgus from 2013 to 2023 at a tertiary academic center. Patients undergoing additional midfoot fusion or with <6-month follow-up were excluded. Patients were grouped by whether supplemental IMS fixation was used, which was determined at surgeon discretion. Demographic, operative, and clinical data were recorded. Radiographic measurements included intermetatarsal angle (IMA) and relative first metatarsal (MT) length preoperatively, immediately postoperatively, and at latest follow-up.

Results: Eighty-nine patients met criteria (51 IMS; 38 no IMS). Baseline demographics and comorbidities were similar between groups. Immediately postoperatively, the IMS cohort demonstrated a smaller IMA (5.8 vs 7.8 degrees, P = .010), which persisted at latest follow-up (7.3 vs 9.3 degrees, P = .015). The IMS group demonstrated a greater reduction in IMA from preoperative to final follow-up (6.9 vs 3.9 degrees, P = .001). Relative first MT length remained greater in the IMS cohort across all time points (P ≤ .045) but change‑score (Postop-Preop) differences in length were not statistically significant. Complication rates, including nonunion (2.0% vs 2.6%), revision surgery (9.8% vs 18.4%), and hardware-related complications (7.8% vs 2.6%), did not differ significantly between groups (P > .05).

Conclusion: Supplemental IMS fixation in first tarsometatarsal arthrodesis for hallux valgus was associated with greater maintenance of radiographic correction without observed differences in complication rates. These findings support IMS augmentation as a potential adjunct in appropriately selected patients.

Level of evidence: Level III, retrospective review.

Background: Clinical data are limited for allograft reconstruction of peroneus brevis tears, and its complication profile remains poorly defined.

Methods: Retrospective chart review was conducted for patients with peroneus brevis tears who underwent tendon reconstruction with semitendinosus allograft at a single tertiary center between March 2010 and July 2019. A total of 68 patients (69 feet), 24 men and 44 women, were identified with mean age at surgery 51.8 (range, 23-74) years and mean follow-up 20.2 (range, 3.4-71.4) months. At the time of chart review, patients were contacted by phone to assess satisfaction, brace use, and work status.

Results: Visual analog scale (VAS) pain score was significantly lower postoperatively (4.0 ± 2.7 vs 2.4 ± 2.8, P = .0018) in the 54 patients with VAS pain data. A total of 40 (58%) feet had at least 1 complication. The most common complications were sural neuralgia in 18 (26%) feet and allograft failure in 7 (10%) feet. Fifteen feet (21%) required reoperation, including 7 for graft failure. In the 30 feet with prior peroneal tendon surgery, there was no association between prior surgery and complications (P = .21). Of the 24 (35%) patients available for phone survey, 20 (83%) were employed prior to surgery and 18 (90%) of these employed patients returned to work and 14 (58%) did not use an assistive device at final follow-up. Sixteen (67%) of the 24 patients contacted reported being very satisfied or satisfied with the procedure.

Conclusion: This is the largest case series to date, demonstrating significant pain improvement and high return-to-work rates in complex cases, but also a 58% overall complication rate and 10% graft failure. Allograft reconstruction may be effective when few options exist, yet careful patient selection and awareness of technical challenges are essential.Level of Evidence: Level IV, case series.

Background: Hallux rigidus is a degenerative condition affecting the first metatarsophalangeal joint. Depending on symptoms, treatment options for symptomatic hallux rigidus include joint resection (such as arthrodesis or arthroplasty) or joint-preserving procedures (like cheilectomy or osteotomies). We present a shortening percutaneous, intra-articular, chevron osteotomy (S-PeICO) technique, which is a modification of the percutaneous intra-articular chevron osteotomy (PeICO) technique previously used to treat hallux valgus. The purpose is to evaluate iatrogenic neurovascular and tendon damage, as well as the accuracy of the osteotomy, including angulation and completion.

Methods: Twelve fresh-frozen below-the-knee cadaveric specimens were used in this study and diagnosed with Coughlin grade I to III hallux rigidus and mild hallux valgus. To evaluate the procedure's safety, the following data were collected: (1) distance between portal 1 and dorsomedial digital nerve, (2) distance between portal 2 and the medial border of the extensor hallucis longus tendon, (3) distance between portal 2 and the dorsomedial digital nerve, (4) distance between portal 2 and the extensor hallucis capsularis, (5) distance between portal 1 and the metatarsophalangeal joint, and (6) distance between portal 2 and the metatarsophalangeal joint. Additionally, the angulation and completion of the osteotomy in the sagittal plane were evaluated.

Results: No significant iatrogenic injuries were detected. The occurrence of minor lesions was 16.6% (2 specimens): one showed a 50% extensor hallucis brevis lesion, and another experienced a complete rupture of the extensor hallucis capsularis tendon. The smallest average distances were observed between portal 1 and dorsomedial digital nerve (3.5 mm) and portal 2 and extensor hallucis capsularis (1.37 mm).

Conclusion: This cadaveric study suggests that S-PeICO is anatomically feasible when performed by experienced surgeons, but narrow safety margins and the potential of tendon lesions should be considered.

Background: Hindfoot nail placement, whether for tibiotalocalcaneal (TTC) arthrodesis or as the index procedure for geriatric ankle fractures or comminuted pilon fractures, is challenging because of anatomical constraints. Although it may be assumed that a straight hindfoot nail should align parallel with the tibial axis, this can lead to either medial calcaneal cortical perforation, varus hindfoot malalignment, or iatrogenic medialization of the foot. This simulation study aims to quantify the angulation required for a straight hindfoot nail to achieve both intraosseous calcaneal placement and preserve native hindfoot alignment in patients without significant coronal plane malalignment.

Methods: We retrospectively analyzed 61 weightbearing computed tomography (WBCT) scans from patients (mean age 43.6 years) with radiographically physiologic hindfoot alignment (mean hindfoot alignment angle: 1.3 degrees, Meary angle: 4.9 degrees). Using multiplanar reconstruction of CT images, 10-mm and 12-mm virtual hindfoot nails were superimposed on each coronal scan. First, the virtual nail was positioned to ensure calcaneal intraosseous placement, defined as ≥2 mm of bone between the nail and the medial calcaneal cortex. The angle between the virtual nail and the tibial anatomic axis was recorded. Second, the virtual nail was repositioned to be parallel to the tibial axis and centered within the tibial canal; medial cortical breach and distance to the medial cortex of the calcaneus were then assessed.

Results: To maintain proper intraosseous calcaneal placement and alignment, a mean valgus angulation of 4.0 degrees (95% CI, 3.5-4.4) for 10-mm nails and 4.9 degrees (95% CI, 4.4-5.4) for 12-mm nails relative to the tibial axis was required. When the nail was aligned strictly parallel to the tibial axis, 60 of 61 scans demonstrated medial calcaneal breach. To avoid this breach, an average medial foot translation of 9.2 mm or iatrogenic hindfoot varus ≥5.8 degrees would be necessary.

Conclusion: This WBCT-based simulation suggests that a valgus orientation of approximately 4 degrees is needed for a straight hindfoot nail to (1) maintain proper calcaneal intraosseous placement and (2) preserve physiologic hindfoot alignment.

Level of evidence: Level III, retrospective cohort study.

Background: Minimal resection total ankle arthroplasty (TAA) has been linked to an increased incidence of tibial component lucency in large preoperative coronal plane deformity. Lucency has been linked to implant loosening. Because radiographic lucency may reflect implant micromotion, lack of bony ingrowth and/or early component loosening, we analyzed a series of TAA cases with varying degrees of preoperative coronal deformity. Our primary aim was to determine if larger preoperative tibiotalar angles were associated with increased postoperative tibial component lucency in the Cadence TAA system.

Methods: A retrospective review of a single surgeon's TAA procedures using the Cadence prosthesis was conducted. Patients aged ≥18 years who underwent Cadence TAA from January 1, 2018, to December 31, 2023, were included; those with <12 months' follow-up or poor-quality radiographs were excluded. Lucency was defined as a radiolucent line at the interface between the tibia and the tibial component that was greater than 0.5 mm at any point. The patient's final follow-up radiograph was used for this analysis. Pre- and postoperative tibiotalar alignment was recorded.

Results: Fifty-five ankles were examined. The average follow-up duration was 29.8 months. Sixteen patients (29%) had no deformity. Twenty-seven patients (49%) had less than 15 degrees of angulation and 12 patients (22%) had more than 15 degrees of angulation. Postoperatively, all ankles were corrected to within 3.7 degrees of a coronal tibiotalar angle of 90 degrees. Comparisons among the 3 groups with χ² tests and analyses of variance revealed no significant differences in tibial interface lucency across any zone (P > .05).

Conclusion: Aseptic loosening in TAAs, indicated by peri-implant lucency, is a recognized mode of failure. Recent studies suggest that preoperative coronal tibiotalar angles greater than 15 degrees increase the risk of failure when using minimal resection TAA. In this short-term, single-surgeon cohort, there were no differences in peri-implant lucency between groups. Findings should be interpreted cautiously, given the limited follow-up and statistical power.

Level of evidence: Level IV, retrospective analysis.

Background: Metal implants, the gold standard for osteotomy fixation in foot surgery, do have inherent problems. A relatively high percentage of patients undergoing hallux valgus correction require secondary surgery for metal implant removal. Although available since the 1980s, bioabsorbable implant use in foot surgery has been limited because of concerns of osteolysis and inferior strength. Magnesium screws are bioabsorbable implants without the inherent risks associated with other bioabsorbable implants. We prospectively compared outcomes of MAGNESIX to metal implants in hallux valgus deformity correction.

Methods: A prospective, randomized study comparing radiographic and clinical outcomes between hallux valgus corrections fixated with magnesium (24 feet) or titanium (25 feet) screws, with an average follow-up of 44 and 35 months, respectively. Clinical outcomes were assessed using the American Orthopaedic Foot & Ankle Society (AOFAS) forefoot score and radiographic parameters measured on weightbearing radiographs pre-operatively and at final follow-up. All complications were documented.

Results: Both magnesium and titanium cohorts showed statistically significant improvements in radiographic parameters (P < .05) and AOFAS scores (P < .05), with no statistically significant difference between cohorts.All post-operative radiographs in the magnesium cohort had visible gas formation at 6 weeks, resolving by 12 weeks, and all screws fully resorbed on final radiographs with no evidence of osteolysis (more than 1 year). Four recurrences occurred in the magnesium cohort vs 3 in the titanium cohort. A single case of hallux varus was noted in the magnesium group and 1 incidence of screw removal for symptomatic hardware in the titanium group.

Conclusion: We found no difference between bioabsorbable magnesium screws and titanium screws for fixation in hallux valgus surgery, although small between-group differences may not have been detectable given the relatively small sample size. Magnesium screws appeared safe with no allergic reactions or wound complications and may offer added benefits of not interfering with advanced imaging, decreasing the need for hardware removal and likely easier revision surgery.

Level of evidence: Level II, randomized controlled trial.