Foot & Ankle Specialist

Total ankle replacement (TAR) is a viable alternative to ankle fusion in certain patients with end-stage ankle arthritis. Despite the importance of understanding alignment and movement of the prosthesis, there is no standardized radiographic method for evaluating the position and movement of the INBONE 2 prosthesis. The aims of this study were to describe a radiographic measurement protocol for INBONE 2 for clinical practice and research while determining the interobserver and intraobserver reliability using standard weightbearing radiographs. Fifteen patients were randomly selected with operative dates from January 2011 to January 2014 who underwent primary TAR using the INBONE 2 prosthesis. Most recent preoperative and first postoperative weightbearing anteroposterior and lateral radiographs were pulled and deidentified. Three foot and ankle surgeons blinded from the patient selection and deidentification, measured the described measurements on separate occasions. Intraobserver reliability: surgeon 1 had acceptable reliability for 9 of 13 continuous radiographic measurements (69.2%), surgeon 2 had acceptable reliability for 8 of 13 measurements (61.5%), and surgeon 3 had acceptable reliability for 12 of 13 measurements (92.3%). Interobserver reliability: among the first measurements, 6 of 13 continuous radiographic measurements (46.2%) had acceptable reliability. Among the second measurements, 7 of 13 measurements (53.8%) had acceptable reliability. Among the first and second measurements combined, 7 of 13 measurements (53.8%) had acceptable reliability. This study promotes the need for meticulous evaluation of annual radiographic findings following TAR in an effort to avoid catastrophic failure and represents moderate agreement can be obtained by employing the proposed measurements for surveillance of INBONE 2 TAR at annual postoperative visits. Measurements on the anteroposterior radiograph appear to demonstrate more consistent results for surveillance than lateral measurements. The intraobserver reliability results were somewhat superior to the interobserver reliability, implying more relevance for a single surgeon applying these measurements annually for postoperative surveillance.

Levels of Evidence: Diagnostic, Level III

Background. Tibiotalocalcaneal arthrodesis is a salvage procedure for patients with complex disease of the ankle and subtalar joints. Despite the clinical efficacy and mechanical advantage of intramedullary nails, complications, such as nonunion, are common. It may be possible to sustain compression in the face of bone resorption and implant loosening over the course of healing using a novel pseudoelastic intramedullary nail with an internal nitinol element. Methods. We identified 15 patients with average age of 54.7 years (range, 28-75 years) who had undergone a tibiotalocalcaneal arthrodesis using a pseudoelastic intramedullary nail. Serial radiographs were used to determine the amount and rate of nitinol element migration over the first 3 postoperative months. Results. Postoperatively, there was at least 2.38 mm of nitinol element migration proximally with mean of 5.58 mm (± 1.38), (range, 2.38-8.11 mm). Average follow-up time was 195 days (± 106.3), (range, 89-490 days). On average, 86% of the total recovered distance took place within the first 39.7 days (±10.03). Conclusions. The nitinol element recovers distance when stretched intraoperatively and maintains moderate compression in response to bone resorption. Further studies are needed to assess if this increased compression lends itself to higher fusion rates than traditional intramedullary nails.

Levels of Evidence: Therapeutic, Level IV: Case series

Ankle fractures are a common injury treated by orthopaedic surgeons. The distal tibiofibular syndesmosis can be injured during these fractures as well as in isolation. They pose a significant challenge with regard to the diagnosis of instability as well as evaluating reduction after fixation. Multiple studies have demonstrated that traditional radiographic analysis fails to accurately identify syndesmotic diastasis, instability, or malreduction. Ankle arthroscopy has been proposed as an alternative way to evaluate the syndesmosis. Ten transtibial amputation cadavers were utilized for this study. Two distinct analyses were undertaken. The first, analysis of instability, utilized 2 dissection groups, a superficial dissection only and a partial disruption instability model. The second analysis was of syndesmotic malreduction. For this, all 10 specimens underwent complete disruption of the syndesmosis and subsequent fixation in either anatomic alignment or malreduction. Both analyses were performed by surgeons blinded to the condition of the syndesmosis. Two groups of surgeons were able to identify syndesmotic instability a combined 75% of the time. Malreduction diagnosis was mixed with a 100% accurate diagnosis of sagittal plane displacement but only 50% accuracy for rotation and 17% for an anatomic reduction. Syndesmotic injury during ankle fracture presents a significant problem to the treating surgeon. Ankle arthroscopy has been shown in the literature to be highly sensitive for diagnosing instability but has not been evaluated in diagnosing malreduction. The current study shows moderate success in diagnosing both malreduction and instability.

Levels of Evidence: Therapeutic, Level V: Basic Science

In the literature, there have been several studies that have analyzed and explained the characteristics of physiological gait in association with pathologies; however, finding information about normal gait pattern while barefoot is difficult. This study focuses on the differences in the barefoot gait between children and adolescents. A total of 320 healthy children and adolescent were recruited and divided into groups according to age: G1 (1-6 years), G2 (7-10 years), G3 (>11 years). Data were collected using a dynamometric platform and analyzed using SPSS software. This study’s findings indicate that there are differences in the swing, stance, load, and single support phases of gait. To our knowledge, this is the first study to present the values of standardized data on barefoot gait pattern in children aged from 2 to 10 years.

Levels of Evidence: Diagnostic, Level IV: Case series

Background. The aim of the study is to create awareness in the practicing health care workers toward the problems encountered during casting and bracing of clubfoot following Ponseti method, and in turn avoid them. Material and Patients. Retrospective audit of 6 years’ clubfoot clinic records to analyze problems associated with Ponseti method. Observations. Problems were encountered in 26 cast and in 6 braced patients. Just 4 patients out of 71 syndromic (5.6%) experienced problems during casting compared with 3% overall incidence. The common problems encountered in casted patients were moisture lesions, hematoma, dermatitis due to occlusion, pressure sores, and fractures. There was excessive bleeding in 1 patient at time of tenotomy. In braced patients, pressure sores and tenderness at tenotomy site were major problems. None of the syndromic patients experienced difficulties during bracing. Conclusions. Problems were encountered with Ponseti method during casting, tenotomy, or bracing. Syndromic children had lesser complication rate than idiopathic clubfeet. It is important to be aware of these problems so that appropriate intervention can be done early.

Levels of Evidence: Level IV: Retrospective

First metatarsophalangeal joint arthritis can stem from a biomechanical imbalance as in hallux abducto valgus, metabolic arthritidies such as rheumatoid or gout, and even in posttraumatic cases. Advanced arthritis in the foot and ankle can often become debilitating. Surgical intervention is often necessary. Revision of failed first metatarsophalangeal joint arthroplasty is often in the setting of bony erosion and lysis, cystic changes, and loss of bone stock. In this article, we describe first metatarsophalangeal distraction arthrodesis technique using tricortical calcaneus autograft with the aim of simplifying donor site graft harvesting and decreasing donor site morbidity while attaining successful osseous union.

Levels of Evidence: Level V

Open reduction internal fixation of posterior malleolus fractures from a posterior approach is gaining popularity. One concern that has not been studied is the risk of iatrogenic injury to anatomical structures on the anterior ankle. The purpose of this study is to determine the proximity of these anterior structures with relation to K-wires advanced through the anterior cortex. A total of 10 cadaver ankles were utilized in the study. A posterolateral approach to the ankle was used. K-wires were advanced at varying levels above the articular surface, and then, the proximity of the wires to the following structures was determined: the neurovascular bundle, tibialis anterior (TA), and extensor hallucis longus. Overall, the structure most in danger of being injured was the TA (P < .001). This tendon was injured by 52% of all K-wires. These data suggest that K-wires should be advanced under direct fluoroscopic visualization to minimize the risk of iatrogenic injury.

Levels of Evidence: Level IV

Calcaneal fractures are complex injuries with high complication rates and they can lead to serious disability. The proper management remains controversial and complications may occur regardless of the chosen type of treatment (operative or nonoperative). The present article reviews the studies that are related to the complications of calcaneal fractures. The incidence, the diagnosis, the prevention and the treatment of these complications were researched and analyzed, with the use of PubMed database, abstracts and original articles in English than investigate the etiology. The aim of the article is to discuss the most suitable management of the complications of calcaneal fractures and recommend a specific treatment as well as prevention methods.

Levels of Evidence: Level IV

The idiopathic toe walking (ITW) gait pattern is characterized in children for walking since the beginning on their first steps on the forefoot; however, these children are able to support their whole foot on the ground. ITW can only be diagnosed in the absence of any orthopaedic or neurological condition known to cause tiptoe walking. The aim of this article is to review other references and provide an outline of the different treatment options, including the 3-step-pyramid insole treatment concept for children with ITW. Methods. Fifty-four articles in English, German, and Spanish were reviewed. There were comparative, retrospective or case studies, classifications or literature reviews and they were divided according with these categories. All the literature reviewed was published between 2000 and 2015. Results. There are some studies that proved the 3-step pyramid insole treatment concept as an effective option compared with other therapeutic modalities such as physical therapy, casting, botolinum toxin type A (BTX), and surgery. Conclusion. There is a wide spectrum regarding the therapeutic options for children with ITW, from physical therapy to surgery options. However, any of these treatment modalities have been reported to be fully successful for the whole toe walking population. Some procedures seem to have achieved faster results or seem to have longer lasting effects. Therefore, further research on the causes of ITW is recommended.

Levels of Evidence: Therapeutic, Level II: Systematic review, prospective, comparative

Tarsal coalition is a bony or fibrous bridge between 2 tarsal bones. The condition is typically congenital and presents in early to mid-adolescence. Common symptoms include ankle pain, stiffness, and limited range of motion. Conservative treatment of tarsal coalition consists of immobilization, short leg walking cast, steroid injections, physical therapy, ankle braces, and orthotics. When conservative care fails, surgical intervention for tarsal coalition includes excision of the coalition or joint arthrodesis. We present a case of a high school football player with a 5-year history of left ankle pain secondary to a talocalcaneal coalition. The athlete did not respond favorably to conservative treatment and underwent a subtalar joint arthrodesis. Prior to surgery, the athlete consented to self-reported functional outcome measures, range of motion measures, and 3D video gait analysis to evaluate the effects of surgery. Measurements were taken prior to surgery and 1½ years after surgery. Clinically significant improvements were seen in subjective outcome measures and functional ankle range of motion in this case. There is limited research available to validate long-term outcomes for current conservative and surgical treatments of tarsal coalition. In this case, joint arthrodesis resulted in a good long-term outcome for this athlete.

Levels of Evidence: Therapeutic, Level IV: Case study

An osteochondral fracture of the metatarsal head is generally the result of direct trauma and is associated with additional proximal fractures of the medially adjacent metatarsals. An isolated osteochondral fracture of the metatarsal head is extremely rare, with only 10 published case reports. Open reduction and internal fixation was performed in 6 of 10 cases and in 2 of 4 chronic cases, each with different implants previously. The mechanism of injury was considered to be shear force in 5 of the reported cases. It is difficult to achieve and maintain reduction in these cases, and the best method for treatment of this type of fracture is unclear. We report a case of an isolated chronic osteochondral fracture of the third metatarsal head in a 14-year-old boy. The boy reported pain in his third metatarsophalangeal joint on dismounting from a bicycle 2 months prior to presentation. He could play soccer at first; however, the pain worsened after running long distances. Therefore, he was referred to our department. Magnetic resonance imaging revealed an osteochondral fracture of the metatarsal head without Freiberg’s disease. We achieved a good result 12 months postoperatively by using open reduction and internal fixation with 2 bioabsorbable thread pins.

Levels of Evidence: Therapeutic, Level IV: Case study

Tibiotalocalcaneal arthrodesis with an intramedullary nail is a procedure reserved for patients who have conditions affecting the ankle joint and subtalar joint. The most common complications include nonunion, malunion, delayed union, infection, periprosthetic fracture, hardware failure, lateral plantar nerve injury, and wound healing. Significant bone void may result if the hardware requires removal secondary to one of these complications. The purpose of this article is to report on 2 cases of infected intramedullary nails, which were revised with fibular inlay strut grafts. Both cases were augmented with either internal or external fixation.

Levels of evidence: Therapeutic, Level IV: Case report

Hindfoot and distal leg neuropathic fracture collapse secondary to normal pressure hydrocephalus is a very rare clinical pathology. The authors present a case of a 69-year-old woman who sustained a distal tibiofibular fracture that resulted in a recurvatum deformity with idiopathic neuropathy and gait instability on initial presentation. A subtalar and ankle joint arthrodesis was performed achieving rectus alignment of the lower extremity with no postoperative complications. Her neuropathic etiology was negative for common causative factors, including diabetes, infection, nutritional deficiencies, congenital neuropathy, and trauma. Approximately 6 months postoperatively, the patient had persistent bilateral lower extremity weakness with the sensation of her “feet sticking to the floor” on ambulation. A referral to neurology revealed a normal pressure hydrocephalus as a possible etiology for her gait abnormalities and neuropathy. She required a ventriculoperitoneal shunt, with resolved gait disturbance and associated weakness approximately 1.5 years postoperatively.

Levels of Evidence: Therapeutic, Level IV: Case report