Foot & Ankle Orthopaedics最新文献

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.

Background: Foot injuries are often missed in polytrauma patients, as more severe injuries may overshadow them, leading to delayed diagnosis and treatment. The aim of this study was to assess the incidence of foot injuries in polytrauma patients, evaluate the timing of their diagnosis, and identify risk factors associated with delayed diagnosis.

Methods: In this retrospective registry-based study, all polytrauma patients with a New Injury Severity Score of ≥16 treated at Tampere University Hospital (TAUH) from 2016 to 2023 were screened for foot fractures as well as Lisfranc and Chopart injuries. Patient demographics, injury characteristics, and timing of diagnosis were extracted from TAUH's trauma registry and analyzed.

Results: Out of 1327 polytrauma patients, 54 (4.1%) sustained foot injuries, totalling 215 foot injuries (195 fractures). Delayed diagnosis, defined as >24 hours between trauma and diagnosis, occurred in 23 patients (43%), involving 80 injuries (37%). Fractures of the midfoot and metatarsus were most commonly diagnosed with delay. Delayed diagnosis was significantly more common in patients with a higher number of foot fractures and injuries (P < .001). Logistic regression analysis identified number of foot injuries (OR 1.658 [95% CI 1.098-2.504 ]), lower Glasgow Coma Scale (GCS) scores (OR 0.582 [95% CI 0.340-0.998]), and presence of concomitant facial injuries (OR 18.227 [95% CI 1.643-202.211]) as independent risk factors for delay in diagnosis.

Conclusion: A substantial portion of polytrauma patients had foot injuries that were diagnosed >24 hours after the time of trauma. Despite these delays, most injuries were minor and without notable clinical consequences. Current tertiary survey protocols effectively detect most major foot injuries requiring immediate attention.

Level of evidence: Level III, retrospective registry.

Background: In orthopaedic foot and ankle procedures, bone debris generated during osteotomies is typically discarded. However, this autograft bone debris has good handling properties and can be amenable for use as a stimulus to bone healing at the site of the osteotomy.

Methods: In the present study, discarded bone debris was harvested intraoperatively during minimally invasive chevron Akin (MICA) hallux valgus corrections, isolated Akin osteotomies of the proximal phalanx of the great toe, cheilectomies, and calcaneal osteotomies from 9 participants.

Results: Multiplex protein arrays of 40 cytokines and 41 growth factors identified 76 immunomodulatory and reparative proteins within the bone debris. Fifteen key growth factors and cytokines (VEGF, PDGF-BB, M-CSF, EGF-R, HGF, ICAM1, GCSF, TIMP-2, sTNFRII, MCP-1, GM-CSF, IL-6sR, IL-10, MCP-2, RANTES) were prominent, suggesting that bone debris proteins may have potential effects on immunomodulation and bone regeneration including cytokine-cytokine receptor interaction, interleukins, MAPK, PI3K-Akt, Wnt, BMP, and TGFβ signaling pathways.Mesenchymal stem/stromal cells (MSCs) were isolated from bone debris of the osteotomies. MSCs expressed genes involved in bone and cartilage formation, homeostasis, angiogenesis, and immunomodulation. Fourteen genes were associated with maintaining cell stemness, whereas seventeen genes were linked to osteochondral development and spatial organization. Additionally, the study identified eight genes promoting angiogenesis and ten genes regulating immune responses in the mesenchymal stem cell environment.

Conclusion: This repurposed surgical waste contains a concentrated array of growth factors, antiinflammatory mediators, and viable MSC that might enhance bone healing when reintroduced to surgical sites.

Clinical relevance: The results could serve as a foundation for repurposing previously discarded bone debris as autologous bone grafts for reimplantation in minimally invasive orthopaedic procedures to potentially enhance bone tissue healing. To confirm clinical relevance, further well-controlled trials are required to establish whether these findings improve bone healing rates and related patient-reported outcomes.

Background: Chronic kidney disease (CKD) is a recognized risk factor for adverse outcomes in total hip and knee arthroplasties; however, its impact on total ankle arthroplasty (TAA) outcomes is limited. This study investigates the association between CKD severity and 30-day postoperative outcomes following TAA.

Methods: We analyzed the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database for primary TAAs between 2006 to 2021. Estimated glomerular filtration rate (eGFR) was calculated, categorizing patients into CKD stages. Univariable analysis assessed associations between eGFR categories, demographic characteristics, and outcomes. Multivariable regression models were used to identify predictors of hospital length of stay, unplanned return to the operating room, and overall complications.

Results: Of the 1678 eligible primary TAA cases, 675 were G1, 806 G2, 136 G3a, 50 G3b, 7 G4, and 4 G5. Significant differences across eGFR categories were found for age, sex, race, anesthesia type, diabetes, hypertension, postoperative dialysis, American Society of Anesthesiologists class, blood urea nitrogen, creatinine, white blood cell count, and hematocrit. The overall complication rate was 3% (53/1678). Rates of myocardial infarction, unplanned return to surgery, and hospital length of stay differed significantly among eGFR groups. Multivariable negative binomial regression identified predictors of longer hospital stay including age 80-89 years, male sex, American Indian / Alaska Native race, unknown race, partial functional dependency, monitored anesthesia care/intravenous sedation, insulin-dependent diabetes, greater or equal to 2 direct complications, and 1 indirect complication. Notably, CKD stage G3b was associated with significantly longer stays compared with G1. Logistic regression revealed that 1 or greater or equal to 2 direct complications and CKD stages G4+G5 significantly predicted unplanned return to surgery. Smokers experienced higher overall complication rates.

Conclusion: In this retrospective observational study, we found that CKD severity significantly impacts postoperative outcomes following TAA, with advanced stages linked to prolonged hospital stays and increased risk of unplanned return to surgery.

Level of evidence: Level III, retrospective cohort series.

Background: Pilon fractures of the distal tibial plafond account for 1% to 10% of all tibial fractures and are often associated with serious complications. As body mass index (BMI) is known to impact post-operative outcomes, particularly infection and nonunion, after trauma, the goal of this study is to explore these trends after pilon fractures.

Methods: A single-center retrospective review of patients undergoing surgical fixation for pilon fractures between January 2013 and June 2023 was conducted. Only patients with at least a 6-month follow-up period were included. Demographic data and injury characteristics were extracted. Post-operative outcomes and complications were computed. Bivariate analysis via t test were applied, followed by multivariate analysis using primary and reduced models to evaluate for poor outcomes. Various BMI cutoffs (≥30, ≥35, ≥40, ≥45) were also employed to evaluate the relationship between outcomes and various obesity categories. Nonunion was assessed at ≥6 months postoperatively.

Results: There were 132 patients included. There was no significant relationship between BMI and infection rates, nonunion rates, and development of post-traumatic osteoarthritis (PTOA) on bivariate analysis (P > .05). On multivariate analysis, diabetes mellitus was a risk factor for infection (P = .01), but BMI was not predictive of any outcomes in the primary or reduced models (P > .05). There were no significant differences in infection, nonunion, and PTOA rates when employing various BMI cutoffs (P > .05).

Discussion: BMI was not found to be an independent predictor of post-operative complications in patients with pilon fractures in this cohort. Our study suggests that pilon fractures are unique and counter historic lower-extremity injury postoperative care protocols that consider weight, although further investigation in larger cohorts with long-term follow-up is required to define this trend.

Level of evidence: Level III, retrospective cohort series.

Background: Injuries to the lateral collateral ligament (LCL) of the first metatarsophalangeal (MTP) joint that are treated surgically are rare. We present 3 cases of traumatic LCL injury of the first MTP joint that were treated surgically for a Stener-like lesion preventing healing. Additionally, we present a review of previously published cases.

Methods: Diagnosis was confirmed with magnetic resonance imaging and intraoperative stress tests, which demonstrated instability and LCL disruption with interposition of the adductor hallucis aponeurosis. All cases were managed operatively with suture anchor repair at the LCL origin or insertion. Patients were followed for 2-4 years postoperatively with outcomes assessed using the Foot and Ankle Outcome Score (FAOS) and the American Orthopaedic Foot & Ankle Society (AOFAS) Hallux Score.

Results: Three LCL repairs were performed in 2 patients, including 1 with bilateral injuries. At final follow-up, both patients had returned to high-level athletic activity. The mean FAOS was 97% and the mean AOFAS Hallux Score was 91.67%. Literature review identified 10 prior case reports with heterogeneous surgical techniques but consistently favorable outcomes.

Conclusion: This series presents a pattern of traumatic LCL injuries with a Stener-like lesion of the great toe that were treated with surgical repair and, to our knowledge, represents the first review of reported cases, offering a synthesis of diagnostic features, operative technique, and outcomes.

Level of evidence: Level IV, case series.