The Incidence of Nonunion of the Hallux Interphalangeal Joint Arthrodesis

Category: Midfoot/Forefoot Introduction/Purpose: Hallux interphalangeal joint (HIPJ) arthrodesis is an effective procedure to treat pain and provide stability, which is often performed for intrinsic pain to the HIPJ. Additionally, this procedure is typically employed in concert with the Jones tenosuspension. Despite that this is an accepted technique, the available literature is scant and questions remain regarding nonunion rates and contributory factors to poor healing. A systematic review of the literature was undertaken to determine the rate of nonunion for HIPJ arthrodesis. Methods: To acquire the highest quality and most relevant studies available, publications were eligible for inclusion only if they involved patients undergoing HIPJ arthrodesis. Studies additionally required mean follow-up of at least six weeks and inclusion of appropriate detail regarding complications, nonunion rates, and patient demographics. Ultimately, 7 studies involving 313 HIPJ arthrodeses met inclusion criteria. Results: A total of 291 patients with a weighted mean age of 48.9 were included. The nonunion rate was 28.3% at a weighted mean follow-up of 8.4 months. The overall complication rate was 33.0%. Conclusion: Considering the increased rate of complications and nonunions for this commonly employed procedure, additional prospective comparative analyses are needed to identify important patient demographics and to determine superior fixation constructs

Accuracy of a Single Tunnel Technique for Reconstruction of the Interosseous Talocalcaneal Ligament

Category: Ankle Introduction/Purpose: Numerous reconstructive techniques to address subtalar joint instability have been described. Interest has focused on direct anatomic repair of the interosseous talocalcaneal ligament (ITCL) with tendon autograft, which is passed through osseous tunnels of the talus and calcaneus within the native anatomic boundaries of the compromised ITCL. To our knowledge, the technique employed to accurately place a guidewire and create a percutaneously developed tunnel through the anatomical footprint of the ITCL to restore it has not been described. The purpose of this study was to confirm that an osseous tunnel could be positioned within the ligamentous footprints accurately and safely, to define anatomic landmarks that can be used as reference points to reproduce an accurate tunnel, and assess the structures at risk during percutaneous reconstruction. Methods: Ten fresh cadaveric below-knee specimens were utilized. Under fluoroscopy, an anterior cruciate ligament guide was utilized to place a drill tunnel from the plantar lateral aspect of the calcaneus, across the sinus tarsi, and through the dorsal medial talus. The monofilament wire was passed through this tunnel to serve as a simulated model for cortical button fixation within the footprint of the ITCL. The first five specimens (group 1) were dissected; structures at risk and wire distance to the center of the ITCL were recorded. The procedure was then performed on the second set of five specimens (group 2) to assess for improvement in our technique. Results: The mean distances from the wire to the ITCL on the calcaneus and talus were 2.92 mm and 4.04 mm, respectively. Mean distances from the wire to ITCL on the calcaneus in groups 1 and 2 were 4.04 mm and 1.80 mm, respectively (p = .04). Mean distances from the wire to ITCL on the talus in groups 1 and 2 were 6.23 mm and 1.84 mm, respectively (p = .08). Violated structures included the tibialis anterior tendon in one specimen, and the most dorsal aspect of the talar head cartilage in 2 specimens. Conclusion: Under fluoroscopic guidance, and with minimal technique experience, a tunnel can be directed across the ITCL footprints accurately and safely. In our last five specimens, we were within 2 mm of the ITCL center, and well within the typical 8.5 mm average ITCL width. In our practice, we have reconstructed the ITCL with a cortical button fixation device using this technique and found it to be efficient and effective

Structures at Risk from an Intermetatarsal Screw for Lapidus Bunionectomy

Category: Midfoot/Forefoot Introduction/Purpose: The Lapidus procedure is a common procedure for the treatment of hallux abducto valgus. Traditional fixation consists of two crossing screws in the sagittal plane. Despite arthrodesis of the first tarsometatarsal joint, recurrence of the hallux abducto valgus deformity remains a concern. A transverse screw spanning the base of the first metatarsal to the base of the second metatarsal has been advocated to provide transverse plane stability. However, the neurovascular bundle is located within the proximity of this screw. The literature is sparse with a standard technique to safely provide appropriate fixation. An anatomic cadaver study was undertaken to assess the risk of injury to the neurovascular bundle. Methods: Ten unmatched cadaveric limbs that had been disarticulated at the knee were used. Under fluoroscopic guidance, the guide wire to a 4.0-mm screw was driven across the base of the first metatarsal and into the second metatarsal. A 4.0-mm screw was inserted, taking care to obtain osseous purchase into the second metatarsal. A longitudinal incision was made and careful dissection was carried to identify the neurovascular bundle and screw. The neurovascular bundle was inspected for trauma and the proximity of the screws was measured using a digital caliper. Results: There were three left-sided and seven right-sided specimens. Five of the specimens were male and five were female. The mean age of the specimens at date of death was 71.4 years. The mean body mass index was 20.5. The mean distance from the 4.0-mm screw to the first metatarsal base 11.24 mm distal to the first tarsometatarsal joint. The deep plantar artery and deep peroneal nerve was free from injury in 10/10 (100%) specimens. However, the screw was measured to be less than 5 mm in three specimens. In these instances, the average distance of the screw distal to the first tarsometatarsal joint was 12.1 mm. Conclusion: The addition of the intermetatarsal screw for Lapidus bunionectomy is widely accepted clinical practice. Descriptions of the operative technique for the placement of hardware into the second metatarsal have not included specific recommendations to avoid potential risk to the neurovascular bundle as it courses between the bases of the first and second metatarsals. According to this cadaveric study, the neurovascular bundle was avoided with placement of the intermetatarsal screw, if placed approximately 11.24 mm distal to the first tarsometatarsal joint. Further study is warranted to evaluate the optimal distance distal to the first tarsometatarsal joint