Treatment of peroneal nerve injuries with simultaneous tendon transfer and nerve exploration

Abstract Background Common peroneal nerve palsy leading to foot drop is difficult to manage and has historically been treated with extended bracing with expectant waiting for return of nerve function. Peroneal nerve exploration has traditionally been avoided except in cases of known traumatic or iatrogenic injury, with tendon transfers being performed in a delayed fashion after exhausting conservative treatment. We present a new strategy for management of foot drop with nerve exploration and concomitant tendon transfer. Method We retrospectively reviewed a series of 12 patients with peroneal nerve palsies that were treated with tendon transfer from 2005 to 2011. Of these patients, seven were treated with simultaneous peroneal nerve exploration and repair at the time of tendon transfer. Results Patients with both nerve repair and tendon transfer had superior functional results with active dorsiflexion in all patients, compared to dorsiflexion in 40% of patients treated with tendon transfers alone. Additionally, 57% of patients treated with nerve repair and tendon transfer were able to achieve enough function to return to running, compared to 20% in patients with tendon transfer alone. No patient had full return of native motor function resulting in excessive dorsiflexion strength. Conclusion The results of our limited case series for this rare condition indicate that simultaneous nerve repair and tendon transfer showed no detrimental results and may provide improved function over tendon transfer alone.http://deepblue.lib.umich.edu/bitstream/2027.42/109530/1/13018_2014_Article_67.pd

Impact of COVID-19 Pandemic on Patients\u27 Perceptions of Safety and Need for Elective Foot and Ankle Surgery in the United States

Background: With the development of the COVID-19 pandemic, elective foot and ankle surgeries were delayed throughout the United States to divert health care resources and limit exposure. Little is known about the impact of COVID-19 on patient\u27s willingness to proceed with elective procedures once restrictions are lifted and factors contributing to such decision. Methods: Patients across 6 US orthopedic institutions who had their elective foot and ankle surgeries cancelled secondary to the pandemic were given a questionnaire. Specifically, patients were asked about their willingness to move forward with surgery once restrictions were lifted and if not why. Pain-level and pain medication use were also assessed. Univariate analysis was used to identify factors that contribute to patient\u27s decisions. Results: A total of 150 patients participated in this study. Twenty-one (14%) opted not to proceed with surgery once restrictions were lifted. Forty-three percent (n = 9) listed concern for COVID infection as the reason; however, 14% of them would proceed if procedures were performed in surgery center. Twenty-nine (19% of the total cohort) patients had increased pain and 11% of patients were taking more pain meds because of the delay to their procedure. Patients who decided not to proceed with surgery reported pain reduction (3% vs 14%) and lower increase in pain medication used (5% vs 12%). Conclusion: COVID-19 has made a significant impact on the health care system. Delay of elective foot and ankle procedures impact patient quality of life and outcomes. Access to surgery centers may provide a partial solution during the pandemic. Level of Evidence: Level III

Why allograft reconstruction for osteochondral lesion of the talus? The osteochondral autograft transfer system seemed to work quite well

Osteochondral lesions of the talus (OCLT) are a challenging entity despite the advancements that have been made to treat focal deficits of articular cartilage. Both autograft and allograft reconstruction have had documented success in the treatment of OLCT. Universal availability and known chondrocyte viability makes the osteochondral autograft transfer system (OATS) an excellent option for recurrent, deep, or moderate defects. For defects with a large diameter, large cystic component, or heavily involving the shoulder of the talus, an allograft provides an excellent option. This article focuses on the efficacy and determination of the most appropriate graft reconstruction: allograft reconstruction or OATS

Posterior pilon fractures: a retrospective case series and proposed classification system

BACKGROUND: Posterior malleolus fractures occur in 7% to 44% of ankle fractures and are associated with worse clinical outcomes. Fractures that involve the posteromedial plafond extending to the medial malleolus have been described previously in small case series. Failure to identify this fracture pattern has led to poor clinical outcomes and persistent talar subluxation. The purpose of this study was to report our outcomes following fixation of this posterior pilon fracture and to describe a novel classification system to help guide operative planning and fixation. METHODS: Eleven patients were identified following fixation of a posterior pilon fracture over a 4-year span; 7 returned at minimum 1-year follow-up to complete a physical examination, radiographs, and RAND-36 (health-related quality of life score developed at RAND [Research and Development Corporation] as part of the Medical Outcomes Study) and American Orthopaedic Foot & Ankle Society (AOFAS) ankle/hindfoot questionnaires. Patient records were reviewed to evaluate for secondary complications or operative procedures. RESULTS: Our mean postoperative AOFAS ankle/hindfoot score was 82. Anatomical reduction of the plafond was noted radiographically in 7 of 11 patients, with the remainder demonstrating less than 2 mm of articular incongruity. Five of 7 patients demonstrated ankle and hindfoot range of motion within 5 degrees of the uninvolved extremity. Four complications required operative intervention; 2 patients reported continued pain secondary to development of CRPS. CONCLUSION: The posterior pilon fracture is a challenging fracture pattern to treat, and it has unique characteristics that require careful attention to operative technique. Our results following fixation of this fracture pattern are comparable with results in the literature. In addition, a novel classification scheme is described to guide recognition and treatment of this fracture pattern. LEVEL OF EVIDENCE: Level IV, retrospective case series

Total ankle arthroplasty versus ankle arthrodesis—a comparison of outcomes over the last decade

Abstract Background The surgical treatment of end-stage tibiotalar arthritis continues to be a controversial topic. Advances in surgical technique and implant design have lead to improved outcomes after both ankle arthrodesis (AA) and total ankle arthroplasty (TAA), yet a clear consensus regarding the most ideal form of treatment is lacking. In this study, the outcomes and complications following AA and TAA are compared in order to improve our understanding and decision-making for care and treatment of symptomatic tibiotalar arthritis. Methods Studies reporting on outcomes and complications following TAA or AA were obtained for review from the PubMed database between January 2006 and July 2016. Results from studies reporting on a minimum of 200 total ankle arthroplasties or a minimum of 80 ankle arthrodesis procedures were reviewed and pooled for analysis. All studies directly comparing outcomes and complications between TAA and AA were also included for review. Only studies including modern third-generation TAA implants approved for use in the USA (HINTEGRA, STAR, Salto, INBONE) were included. Results A total of six studies reporting on outcomes following TAA and five reporting on outcomes following AA met inclusion criteria and were included for pooled data analysis. The adjusted overall complication rate was higher for AA (26.9%) compared to TAA (19.7%), with similar findings in the non-revision reoperation rate (12.9% for AA compared to 9.5% for TAA). The adjusted revision reoperation rate for TAA (7.9%) was higher than AA (5.4%). Analysis of results from ten studies directly comparing TAA to AA suggests a more symmetric gait and less impairment on uneven surfaces after TAA. Conclusions Pooled data analysis demonstrated a higher overall complication rate after AA, but a higher reoperation rate for revision after TAA. Based on the existing literature, the decision to proceed with TAA or AA for end-stage ankle arthritis should be made on an individual patient basis

Effect of First Metatarsophalangeal Joint Arthrodesis on PROMIS Functional Outcomes and Radiographic Alignment for Hallux Rigidus

Category: Midfoot/Forefoot Introduction/Purpose: Improvement in first ray alignment after arthrodesis of the arthritic first metatarsophalangeal (MTP) joint has been shown, yet few studies have attempted to correlate radiographic alignment with functional outcomes. The purpose of this study was to determine if 1st MTP joint deformity due to hallux rigidus correlates with patient reported pain and function, and whether there is a correlation between outcomes and radiographic measurements made before and after surgery. We also sought to determine how 1st MTP joint arthrodesis affects patient reported pain and function in a series of patients with hallux rigidus using a validated outcome measure. Methods: We conducted a retrospective study on patients treated with 1st MTP joint arthrodesis for diagnosis of hallux rigidus from 2012 to 2014 using a single surgical technique. The hallux-valgus angle (HVA), intermetatarsal angle (1-2 IMA) and lateral talar first metatarsal angle (L1TMTA) were measured independently by the senior author and an Orthopaedic Surgery fellow on pre- and post-operative radiographs. Inter-observer and intra-observer coefficients of repeatability were calculated. Pre- and post- operative physical function and pain scores were generated using the Patient Reported Outcome Measurement Information System (PROMIS). Paired t-test was used to detect differences. Bivariate analysis was used to assess radiographic measurement and PROMIS score correlation. Results: 30 subjects met inclusion criteria for radiographic analysis. Mean pre- and post-operative IMA, HVA and LT1MTA are shown in Table I. 23 subjects had pre-operative PROMIS data. Mean pre-operative pain and function were 72.7 and 32.0. Only pre-operative HVA significantly correlated with pre-operative physical function scores, with Pearson correlation value of 0.507 (p = 0.014). 7 subjects had pre- and post-fusion PROMIS data with average follow up 173 days post-fusion (minimum 130, maximum 196). Mean change in pain and function were -9.14 (p = 0.094) and 6.57 (p = 0.31), respectively. Only change in patient reported pain significantly correlated with change in HVA, with a Pearson correlation value of -0.76 (p = 0.05). Interclass correlation coeffecients for interoperator reliability ranged from 0.835 to 0.998. Conclusion: 1st MTP joint arthrodesis significantly improved radiographic IMA, HVA and LT1MTA for patients with hallux rigidus. In a small series of patients, arthrodesis improved patient reported pain and function, but this was not significant. Only pre-operative HVA correlated with pre-operative physical function, while only change in HVA correlated with change in patient reported pain after arthrodesis. Special attention should be paid to the HVA for the patient undergoing 1st MTP arthrodesis for hallux rigidus