Foot & Ankle Specialist

Background: The Weil oblique distal metatarsal osteotomy is regularly used in the treatment of primary metatarsalgia. The most frequent complication is the floating toe, which occurs in up to 36% of postoperative follow-up. The theory of reducing the plantar flexor mechanism tension associated with the retraction of the dorsal structures during the healing process of the surgical procedure may explain this negative evolution. Objective: This study aimed at assessing the effectiveness of the Tucade dorsal thermoplastic locking orthosis in the prevention of floating toe after Weil osteotomy. Methods: In all, 30 patients with metatarsalgia diagnosis submitted to Weil osteotomy were treated in the postoperative period with the Tucade dorsal thermoplastic locking orthosis. Results: The floating toe was not observed in this case series. There was 1 case of superficial wound irritation at the dorsal surgical incision and 1 case that evolved with transfer metatarsalgia. Statistical analyses were performed—American Orthopaedic Foot and Ankle Society Scale for lateral toes and extension of the lateral toes—using the t test, and P < .0001 was obtained for comparison of the preoperative and postoperative periods in the population studied. Conclusion: The Tucade dorsal thermoplastic locking orthosis during the postoperative period of Weil osteotomy proved to be effective in the prevention of floating toes.

Level of Evidence: Therapeutic Level IV: Case Series

Because of the complex anatomy of the foot, rarity of fractures of the foot, and subtle radiographic cues, foot injuries are commonly overlooked and mis/undiagnosed. This study seeks to investigate a patient population whose peritalar injuries, including fractures and dislocations, were missed on initial examination, in order to analyze factors of known, missed injuries and provide insight into methods for reducing the incidence of missed diagnoses. Surgical cases between January 1999 and May 2011 were queried and retrospectively reviewed to identify missed peritalar injuries. Of 1682 surgical cases reviewed, 27 patients with missed peritalar injury(ies), which were subsequently confirmed by imaging studies, were identified. Using the Orthopaedic Trauma Association classification, fracture and dislocation subtypes were classified. A medical record review was performed to assess demographic and surgical data elements. In this study population, 7 types of peritalar injuries (talus, calcaneal, navicular, and cuboid fractures as well as subtalar, calcaneocuboid, and talonavicular joint dislocations) were diagnosed in 27 patients. All patients required surgical intervention. Talus fractures were the most commonly missed injury. In patients with multiple peritalar injuries, there was a strong correlation between talus and navicular fractures (r = −0.60; P < .01) as well as a moderate correlation between talus fractures and calcaneocuboid dislocations (r = −0.46; P = .02). The presence of a calcaneal fracture significantly decreased the time to definitive diagnosis (P = .01). Male patients’ diagnoses were delayed an average of 324 days and females 105 days (P = .04). A moderate correlation was found between patient age at injury and time to diagnosis (r = −0.47; P = .04), with a decreased time to diagnosis as patient age increased. Significant factors were identified in this patient population, including patient sex and age, which may contribute to missed or delayed diagnosis in the clinical setting. Prompt and accurate diagnosis of peritalar injuries may improve long-term outcomes.

Levels of Evidence: Care Management, Level V

The purpose of this study was to evaluate a series of patients undergoing a single platelet-rich plasma (PRP) injection for the treatment of chronic midsubstance Achilles tendinopathy, in whom conservative treatment had failed. Thirty-two patients underwent a single PRP injection for the treatment of chronic midsubstance Achilles tendinopathy and were evaluated at a 6-month final follow-up using the Foot and Ankle Outcome Score and Short Form 12 general health questionnaire. Magnetic resonance imaging was performed on all patients prior to and 6 months after injection. Twenty-five of 32 patients (78%) reported that they were asymptomatic at the 6-month follow-up visit and were able to participate in their respective sports and daily activities. The remaining 7 patients (22%) who reported symptoms that did not improve after 6 months ultimately required surgery. Four patients went on to have an Achilles tendoscopy, while the other 3 had an open debridement via a tendon splitting approach. A retrospective evaluation of patients receiving a single PRP injection for chronic midsubstance Achilles tendinopathy revealed that 78% had experienced clinical improvement and had avoided surgical intervention at 6-month follow-up.

Levels of Evidence: Therapeutic, Level IV: Retrospective case series

Cystic talar shoulder defects are particularly challenging osteochondral lesions. A retrospective chart review was performed on 13 adults that previously failed microfracture, presented with medial cystic osteochondral lesions of the talus, and were treated with malleolar osteotomy and subchondral allograft reconstruction. The aim of the study was to evaluate the effect of a medial malleolar osteotomy and allograft subchondral bone plug on pain and function. We hypothesized that following surgery, pain and function would significantly improve. Compared with preoperative measures, pain (first step in the morning, during walking, at the end of the day) and function (descending the stairs, ascending the stairs, and ambulating up to 4 blocks) improved postoperatively at 6 and 12 months (P ≤ .001). During each activity, pain improved postoperatively from 6 to 12 months (P ≤ .006). Postoperatively, from 6 to 12 months, the level of disability improved while descending the stairs (P = .004), and the level of disability experienced while ascending the stairs and ambulating up to 4 blocks was maintained (P ≥ .02). Multiple regression analyses identified body mass index as a predictor of preoperative function (R² = .34, P = .04). No variables were identified as significant predictors of postoperative pain or function. With all osteotomies healing, no graft rejection, and a single deep venous thrombosis, allograft subchondral plugs appear to successfully treat osteochondral lesions of the talus with improvements in pain and function as well as an acceptable complication rate.

Level of Evidence: Therapeutic, Level IV: Retrospective Case Series.

Introduction: Avascular necrosis (AVN) of the talus is a challenging entity to treat. Poor outcomes remain all too common. The purpose of this systematic review was to: identify and summarize all available evidence for the treatment of talar AVN; provide treatment recommendations; and highlight gaps in the literature. Methods: We searched MEDLINE and EMBASE using a unique algorithm. The Oxford Level of Evidence Guidelines and GRADE recommendations were used to rate the quality of evidence and to make treatment recommendations. Results: 19 studies fit the inclusion criteria constituting 321 ankles at final follow-up. The interventions of interest included hindfoot fusion, conservative measures, bone grafting, vascularized bone graft, core decompression, and talar replacement. All studies were Level IV evidence. Due to study quality, imprecise and sparse data, and potential for reporting bias, the quality of evidence is “very low”. Studies investigating conservative therapy showed that prolonged protective weight bearing provides the best outcomes in early talar AVN. Discussion: Given the “very low” GRADE recommendation, understanding of talar AVN would be significantly altered by higher quality studies. Early talar AVN seems best treated with protected weightbearing and possibly in combination with ESWT. If that fails, core decompression may be an attractive treatment option. Arthrodesis should be saved as a salvage procedure. Future prospective, randomized studies are necessary to guide the conservative and surgical management of talar AVN.

Level of Evidence: Level II

First metatarsophalangeal (MTP) arthrodesis is a well-accepted procedure for the treatment of end-stage hallux rigidus. Despite the excellent and predictable clinical results, the procedure does not address the metatarso-sesamoid joint complex. There has been one case report of arthritis of the metatarsal sesamoid joint as uncommon cause of post–arthrodesis hallux pain. Additionally, we have noted this complication in our practice as well despite the paucity of reported cases in the published literature. Resection of either the tibial or fibular sesamoid is an acceptable treatment for recalcitrant sesamoid pain; however, resection of both the tibial and fibular sesamoids as would be required for arthritic changes is not encouraged to prevent the risk of a cock-up toe deformity. Arthrodesis of the first MTP joint eliminates the possibility of this complication. Resection of the sesamoids following a first MTP fusion requires a separate incision with additional morbidity and risk to the medial plantar digital nerve. This second surgical intervention is not without morbidity and carries additional cast to the patient, which can be avoided if the pathology is appropriately identified preoperatively. We describe the surgical indications and novel technique for a first MTP arthrodesis and total sesamoid resection through a standard dorsomedial incision. The approach adds minimal surgical time and morbidity and eliminates the source of plantar first MTP pain that is present in a cohort of patients with hallux rigidus.

Levels of Evidence: Level IV, Case Series

We describe a sonographically guided technique to perform therapeutic injections for anteromedial ankle impingement syndrome. Scans are carried out using a high-frequency small footprint linear array transducer, positioned along the anteromedial aspect of the tibiotalar joint. A 25 gauge needle is advanced under direct sonographic guidance into the “meniscoid lesion” (area of scarring), and a standardized therapeutic mixture is injected extra-articularly. Image-guided injections have a positive influence on clinical decision making by improving patient management, increasing the accuracy of diagnosis, and decreasing patient pain. Sonography allows confirmation of correct injection placement, resulting in increased accuracy and more successful patient outcomes.

Levels of Evidence: Therapeutic, Level V, Expert Opinion

Osteochondral lesions of the talar dome are increasingly diagnosed and are a difficult pathology to treat. Conservative treatment yields best results in pediatric patients, often leaving surgical options for adult populations. There is a paucity of long-term data and comparisons of treatment options. Arthroscopic bone marrow stimulation is a common first-line treatment for smaller lesions. Despite promising short to medium term clinical results, bone marrow stimulation results in fibrocartilagenous tissue that incurs differing mechanical and biological properties compared with normal cartilage. Autologous osteochondral transplantation has demonstrated promising clinical results in the short to medium term for larger, cystic lesions and can restore the contact pressure of the joint. However, concerns remain over postoperative cyst formation and donor site morbidity. Recent developments have emphasized the usefulness of biological adjuncts such as platelet-rich plasma and concentrated bone marrow aspirate, as well as particulate juvenile cartilage, in augmenting reparative and replacement strategies in osteochondral lesion treatment. The purpose of this article is to review diagnosis and treatment of talar osteochondral lesions so that current practice guidelines can be more efficiently used given the available treatment strategies. A treatment paradigm based on current evidence is described.

Levels of Evidence: Therapeutic, Level V, Expert Opinion

Macrodystrophia lipomatosa (MDL) is a rare, nonhereditary, congenital malformation that primarily affects the proliferation of mesenchymal structures. It presents with localized macrodactyly of one or more digits. The characteristic pathology is associated with hypertrophic fibroadipose tissues, more so to the plantar aspect of the foot. This condition can pose a threat to vascular supply, innervation, and even joint function. We present a single case of a 4-year-old male patient who presented with progressive enlargement of a unilateral left fifth digit since birth. The patient became increasingly symptomatic. Amputation was the selected treatment, and on pathological review of the specimen, the diagnosis of MDL was confirmed. The patient is approximately 1 year postoperative and has recovered uneventfully with an improved quality of life. The purpose of this article is to raise awareness of this condition with an emphasis on diagnosis through ancillary imaging results.

Levels of Evidence: Therapeutic, Level IV: Case report

Open fractures with complete extrusion of talus are high-energy injuries. While treating these injuries, union of the fracture, vascularity of the body, and possibility of infection are main issues predicting less favorable outcomes. At present, there are no recommended treatment protocols for the management of such injuries. Early debridement, wound care, anatomic reduction, and adequate fixation are key factors in the management of compound injuries of the talus. There are few reports in the literature on successful reimplantation of talus when it is completely extruded. Encouraging functional outcomes of reimplantation of extruded talus suggest that excision of the talus with or without tibiocalcaneal fusion should be kept as a salvage procedure. We report a case of a farmer who sustained fracture of the talar neck. Both head and body fragments were completely extruded from the wound on the anterolateral aspect of the ankle. The patient was treated 18 hours postinjury. Thorough debridement of wound and bony fragments was done. Talus was reimplanted and fixation was performed with Kirschner wires. At 3-year follow-up, satisfactory functional outcome was noted with AOFAS (American Orthopaedic Foot and Ankle Society) score of 83 and MOXFQ (Manchester–Oxford Foot Questionnaire) scale score of 23. The purpose of presenting this case is to demonstrate the successful outcome of reimplantation of talus.

Level of Evidence: Therapeutic, Level IV: Case study