Evaluation of Outcomes Following Lesser Toe Metatarsophalangeal Interpositional Arthroplasty with Semitendinosus Allograft with Description of the Anchovy Technique

Category: Lesser Toes Introduction/Purpose: Lesser toe metatarsal head degeneration and collapse can cause significant pain and disability. If conservative measures fail, there is not a clear surgical solution, particularly in the setting of bone loss. A wide variety of causes of lesser metatarsophalangeal (MTP) joint degeneration exist, including Freiberg’s disease, failure of previous surgery, and primary osteoarthritis. Previous studies have evaluated joint preserving osteotomies; however, they do not offer a solution for complete head collapse. Isolated metatarsal head excision is associated with poor outcomes. The purpose of our study was to evaluate clinical outcomes and review radiologic finding after lesser toe MTP interpositional arthroplasty with semitendinosus allograft and to describe the technique. To our knowledge, this technique and its outcomes have not been described for the lesser toes. Methods: We retrospectively reviewed a consecutive series of patients treated by three foot and ankle trained surgeons at one institution from 2007-2017. We identified sixteen patients who underwent allograft interpostional arthroplasty for the second or third MTP joint. We performed a retrospective chart review to obtain demographics, diagnosis, range of motion, and concomitant procedures. A phone survey was created to evaluate satisfaction, pain, and likelihood to repeat the surgery. Foot and Ankle Ability Measure (FAAM) scores were reviewed. Preoperative and postoperative radiographs were reviewed for preservation of metatarsal lengths and cascade. The procedure was performed through a dorsal midline approach to the MTP joint. Osteophytes were removed and a cannulated reamer created a concavity in the metatarsal head. A semitendinosus allograft was then rolled and sutured into a ball, which was approximately 1.5 cm in diameter. The allograft was secured to the medullary canal with a suture anchor. Results: Fourteen patients underwent 2nd MTP interposition, and two patients underwent 3 rd MTP interposition arthroplasty. The average age of the patients were 51.3 years (median 53.4, range 24-61), and the average follow up was 3.4 years. Seven patients had multiple procedures. The diagnoses included six primary osteoarthritis, four Freiberg’s disease, two failed prior surgery. Preoperative FAAM showed the patients were able to complete 73% of activities of daily living and 63% of sport specific activities. Average MTP dorsiflexion was 27 and 30 degrees before and after surgery, respectively. Radiographically, preoperative metatarsal length ranged from 9.36 - 12.63 cm. Postoperatively, the metatarsal length added to the space filled by the allograft ranged from 9.65 cm - 11.77 cm. Conclusion: Interpositional arthroplasty of the lesser MTP joints with a rolled semitendinosus allograft, secured with a suture anchor, provides a unique solution to a difficult problem. This procedure allows the surgeon to fill a bony void and replace collapsed metatarsal head. This study shows patient reported outcomes based on phone survey and FAAM scores, where pain caused significant limitations before surgery. This study also showed preservation of range of motion after surgery. Radiographic review suggests that length of the affected metatarsal can be maintained, bone voids can be filled, and the cascade of the metatarsals can be preserved

The corrective ability of the double chevron and Akin osteotomies on medial sesamoid position in Hallux Valgus deformity

Category: Bunion Introduction/Purpose: Recurrence of hallux valgus deformity is a common post-operative complication with rates in the literature ranging from 2.7 – 30%. Lateral displacement of the great toe medial sesamoid is correlated with a high recurrence rate, and failure to reduce sesamoid position has been implicated as a risk factor for recurrence due to an uncorrected deforming force. Sesamoid position has been studied in relation with Scarf osteotomy, but not other corrective osteotomies. The goal of this study is to determine the efficacy of the double chevron and Akin osteotomy in reducing the great toe medial sesamoid. Methods: We retrospectively reviewed all patients in the last five years undergoing hallux valgus correction via the double chevron and Akin osteotomy method with pre-operative and post-operative weight bearing radiographs. We measured sesamoid position pre and post-operatively using the Hardy-Clapham (HC) scale of I-VII with V or greater representing a laterally displaced medial sesamoid. We also measured hallux valgus and inter-metatarsal angles. Measurements were made by three authors in orthopedics and one in radiology. We used intra-class correlation coefficient (ICC) to determine inter-observer agreement and establish reliability. With adequate ICC, we could consider the lead author’s measurements as representative of the group. We examined the percent of hallux valgus cases with displaced sesamoids pre-operatively. Next, we determined how many of those cases did we reduce the sesamoids to grade IV or less. Finally, we performed subgroup analysis for pre-operative HC grades V, VI, and VII to determine correction percentage by severity. Results: There were 49 patients with 53 feet treated with the double chevron and Akin osteotomies for hallux valgus correction. Of these, 39 (73.6%) had significant preoperative lateral displacement of the medial sesamoid characterized by HC grade of V or greater. We corrected 30/39 (77.0%) to a reduced position of HC grade IV or less (p-value 0.048). In sub-analysis, we achieved reduction of the medial sesamoid position in 14/14 feet (100%) with HC grade V, 6/9 feet (66.7%) with HC grade VI, and 10/16 feet (62.5%) with HC grade VII (p-value 0.037). The ICC was 0.91 for pre-operative HC scores and 0.79 for post-operative HC scores. Average pre and post-operative HVA was 29.4° and 8.7°, respectively. Average pre and post-operative IMA was 13° and 5.2° respectively. Conclusion: Our study validates the double chevron and Akin osteotomies as effective in correcting sesamoid position. We achieved correction in 30/39 (77%) cases with initial sesamoid displacement. For mild cases of displacement with HC grade V, sesamoid correction was always achieved, and we were likely to achieve correction in the more severe cases of sesamoid displacement with HC grade VI or VII as well. The technique is also effective at reducing HVA and IMA. We had acceptable inter- observer agreement which supports the reliability of our methods. Future studies should examine recurrence rate following the double chevron and Akin osteotomies prospectively

Outcomes of Lisfranc Injuries Treated with Joint Preserving Fixation

Category: Midfoot/Forefoot Introduction/Purpose: Open reduction and internal fixation with transarticular screws to stabilize Lisfranc injuries may increase the risk of arthritis or affect outcomes. Extra-articular or bridge plating to stabilize these injuries avoids this articular damage. This study analyzes the functional outcomes and complications in patients who underwent this type of joint preserving fixation for Lisfranc injuries. Methods: A retrospective review of all patients treated for a Lisfranc injury at a level 1 trauma center from July 2008 to October 2015 was conducted. Patients over 18 years of age who were not incarcerated and did not have any concomitant procedures in the lower extremities were included. Patient electronic medical records were reviewed. Outcomes were analyzed with AOFAS scores. Results: There were 16 patients included in the study with an average follow up time of 57 months (15 - 102 months). Average AOFAS score was 79 (SD 16) and time to return to regular activities was 35 weeks (SD 25 weeks). Seven patients (44%) had their hardware removed during the follow up period. There was 1 complication which comprised of a screw backing out and needing to be removed. Conclusion: In the present case series, joint preserving fixation for Lisfranc injuries offered similar AOFAS scores as those reported for ORIF with transarticular screws, but with a decreased rate of hardware removal and need for mid-foot fusion