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

FAAM ADL Scores Correlate with PROMIS Physical Function, Pain Interference, and Depression Outcomes

Category: Midfoot/Forefoot Introduction/Purpose: Legacy patient-reported outcome instruments like the FAAM Activities of Daily Living (ADL) quantify patient disability but are often limited by responder burden and incomplete questionnaires. The Patient-Reported Outcome Measurement Information System (PROMIS) overcomes such obstacles through computer-adaptive technology to collect data on various health domains including Physical Function (PF), Pain Interference (PI), and Depression. Few reports, though, have examined PROMIS tools in lower extremity patients, and no study has examined PROMIS psychosocial outcomes like PI and Depression in foot and ankle conditions. We investigated the relationship between FAAM ADL and PROMIS measures, hypothesizing that FAAM ADL and PROMIS scores would correlate. Methods: All new patients with either a primary or secondary diagnosis of hallux valgus based on clinic billing codes from July, 2015 – February, 2016 were retrospectively identified. Patients with complete FAAM ADL paper-based surveys and electronic PROMIS questionnaires for PF, PI, and Depression were included. Spearman rho correlations were performed between FAAM ADL and PROMIS scores. Bivariate and multivariate analyses were then performed to identify differences in FAAM ADL and PROMIS PF measures based on select demographic variables (gender, comorbidities, marital status, employment status, prior foot and/or ankle surgery, and smoking status). Significant variables (P 0.1). Regression analyses demonstrated that PROMIS PI scores alone accounted for significant portions of the variance in FAAM ADL (R2 = 0.44, P < 0.001) and PROMIS PF (R2 = 0.57, P < 0.001) measures. Conclusion: PROMIS PF, PI, and Depression scores all correlated with FAAM ADL scores, highlighting the importance of understanding functional and psychosocial disability when assessing outcomes in lower extremity patients. Further, PROMIS PI results predicted significant portions of FAAM ADL and PROMIS PF scores, suggesting that function and pain are interrelated when measured by either traditional or modern outcomes instruments

Comparison of Total Ankle Replacement and Ankle Arthrodesis During the Recovery Period

Category: Ankle, Ankle Arthritis Introduction/Purpose: Two reliable surgical alternatives exist for end-stage ankle arthritis, ankle arthrodesis and total ankle replacement. Several comparative studies have shown similar clinical results between the two procedures at intermediate-term follow-up (2 to 6 years). Despite this comparative literature, no studies have been dedicated to determining which of the two procedures allows better function and pain during the recovery period (the first 6 months following the procedure). This information is especially beneficial to patients for whom a more difficult and longer recovery is particularly adverse, such as elderly patients or patients with medical comorbidities. It is also unclear if pain or dysfunction during the recovery period correlates with intermediate-term complications such as nonunion or prosthetic loosening. Methods: This is a single site retrospective case-control study. Patient-Reported Outcomes Measurement Information System (PROMIS) scores have been completed by patients at the orthopedic foot and ankle clinic at each visit since October 2014. Patients who have undergone either a total ankle replacement or an ankle arthrodesis during that timeframe were evaluated to determine their level of pain, function, anxiety and depression at a given interval (from preoperative to 6 months) during their recovery. Data acquisition was via chart review. Exclusion criteria included Charcot neuroarthropathy and inadequate data. Results: 138 procedures (58 total ankle replacements, 80 ankle arthrodeses) were performed at our institution during the study period. Chart review of patients meeting inclusion criteria is currently being conducted to record PROMIS scores, adjuvant procedures, complications, return to work and post-operative protocol during the first 6 months following the procedure. Data analysis will be undertaken, to detect a minimally important difference between PROMIS scores, with a 95% confidence interval and power of 0.8, the minimal sample size was calculated to be 44 subjects in each group. For patients who developed a complication from surgery (non-union, implant loosening, infection, etc.), scores will be reviewed to determine if abnormal PROMIS scores early on in the recovery period correlate with future complications. Conclusion: Patient pain and function during the first 6 months following surgery is an important consideration for those contemplating both ankle arthrodesis and replacement as options. Data collected from this study to be completed by Spring 2017 will help to clarify if differences between the two procedures exist

A Comparison of Wound Complications With Surgical Treatment of Achilles Tendon Conditions Using 2 Surgical Approaches

Background: Wound complications are a concern with the open treatment of Achilles tendon conditions. The location of the incision may impact the risk of wound complications because of its relationship to the blood supply to the skin. There is no consensus as to the safest incision location. The purpose of this study was to evaluate and compare the rates of sural nerve injury and wound complications including superficial or deep infections and wound dehiscence between posterior midline and posteromedial surgical incision locations. Methods: 125 patients with Achilles tendon rupture or Achilles tendinopathy were treated with open surgery through a longitudinal posterior midline or posteromedial incision. An L-shaped incision was used in the posteromedial group for cases of insertional repair. Postoperative complications including sural nerve injuries, superficial wound complications, superficial infections, deep wound infections, return to the operating room, and need for soft tissue coverage were recorded and rates were compared between the groups. Results: No significant differences were detected between the posteromedial and posterior incision groups in rates of sural nerve injuries, superficial infection, or deep wound infection. The posterior incision group had significantly fewer wound complications. The wound complications in the posteromedial group primarily occurred when an L-shaped incision was used for insertional repair. No patients in either group required debridement or soft tissue/flap coverage. Conclusion: The posterior incision location had significantly fewer wound complications. The use of an L-shaped incision was likely responsible for the wound complications in this group rather than the location of the incision. The use of a medial incision was not found to decrease the rate of sural nerve injury. Level of Evidence: Level III

Revision Arthrodesis in the Foot and Ankle

Category: Ankle Arthritis Introduction/Purpose: Arthrodesis is a common surgical procedure used to manage arthritis and deformity in the foot and ankle. Nonunion or failure of the bone to fuse, is a known possible outcome in any arthrodesis surgery and often presents as persistent pain and swelling after an arthrodesis procedure. Published rates of nonunion in the foot and ankle literature range from 0 to 47 % depending on the patient population and joint involved. Multiple factors can contribute to developing a nonunion including; arthrodesis location, fixation method, tobacco use, diabetes, infection and others. Methods: The case logs of three fellowship trained foot and ankle surgeons were reviewed from January 2007 to September 2014. ICD-9 code 733.82 (nonunion fracture), 998.89 (miscellaneous complication), and a word search for nonunion in case logs were used to identify subjects. The clinical charts were reviewed for patient factors incuding: diabetes, inflammatory arthropathy, tobacco use, history of infection, prior nonunion elsewhere in the body, neuropathy, Charcot arthropathy, post-traumatic arthritis, and prior attempt at revision arthrodesis at the same clinical site. Surgical records were reviewed to identify location of the nonunion, type of instrumention, use of structural allograft, use of cancellous autograft (CA), use of iliac crest bone marrow aspirate (ICBMA) and use of orthobiologics such as bone morphogenetic protein (BMP) during the revision arthrodesis. Successful revision was defined as radiographic union in the final x-ray taken during follow-up by the attending orthopaedic surgeon and radiologist. Results: Eighty-two cases of revision arthrodesis were identified. The overall nonunion rate during revision arthrodesis was 23%. The average length of follow up was 16 months. Univariate analysis was performed on the patient and surgical factors to determine influence on nonunion rates. Of these factors, statistical analysis identified only neuropathy and prior attempts at revision as significant risks (P< .05) for persistent nonunion. Odds ratio calculated based on previous attempts at revision arthrodesis found a 2.8 fold increase in the risk of failure for each previous attempt at revision. Charcot arthropathy approached significance at p=.051, but was limited by its small sample size (n=2). Smoking, location, use of orthobiologics and other clinical factors did not prove significant. Please see table for further details. Conclusion: Revision arthrodesis for nonunion in the foot and ankle can be highly successful (77%) under a variety of patient and surgical conditions. Neuropathy is a significant patient risk factor for persistent nonunions and is important to identify even in the non-diabetic patient. As the number of attempts at revisions increases there is a subsequent 3-fold increase in the risk of persistent nonunion

Rheumatoid forefoot reconstruction in the non-rheumatoid patient

Category: Lesser Toes, Midfoot/Forefoot Introduction/Purpose: Residual pain and recurrent deformity following forefoot surgery can cause significant disability. In patients with rheumatoid arthritis, first metatarsophalangeal (MTP) joint arthrodesis with lesser metatarsal head resection – often referred to as a rheumatoid forefoot reconstruction – has been shown to be a reliable operation for pain relief and deformity correction. Limited data, however, has been published on outcomes of the same forefoot reconstruction operation in the non- rheumatoid patient. Here, we review our experience with this procedure in patients without rheumatoid disease, hypothesizing improved clinical and radiographic outcomes following surgery. Methods: Following chart review and surveying billing codes, we retrospectively identified patients from 2007-2015 without a diagnosis of rheumatoid arthritis who underwent first MTP arthrodesis with lesser metatarsal head resection (rheumatoid forefoot reconstruction). Phone surveys were then conducted to assess clinical outcomes including pain and satisfaction scores. Preoperative and postoperative radiographs were reviewed for 1, 2 intermetatarsal angle (IMA), hallux valgus angle (HVA), 2nd MTP angle (MTP-2), and lesser MTP alignment (in both sagittal and axial planes). Postoperative radiographs were also assessed for radiographic union. Results: We identified 14 non-rheumatoid patients (16 feet) who underwent forefoot reconstruction – of those, 13 patients (15 feet) were successfully contacted via follow-up phone survey. Mean postoperative follow up was 42.3 (range: 12-76) months from surgery to phone interview. Mean postoperative satisfaction scores were 9.1 (out of 10), and no patients required further surgery after forefoot reconstruction. Pain scores significantly decreased from 6.2 preoperatively to 2.0 postoperatively (P<.001). Radiographic parameters (IMA, HVA, MTP-2, and lesser MTP alignment in the sagittal plane) all improved with surgery (P<.05). All 16 feet achieved union of the first MTP arthrodesis. Conclusion: With decreased pain, high satisfaction rates, and improved radiographic parameters, first MTP arthrodesis coupled with metatarsal head resection (rheumatoid forefoot reconstruction) is a viable surgical option for non-rheumatoid patients who have failed prior attempts at forefoot reconstruction or have chronic forefoot pain with deformity

Preoperative Emotional Distress Negatively Impacts Patient-reported Outcomes Following Foot and Ankle Surgery

Category: Other Introduction/Purpose: Prior work has demonstrated that greater preoperative emotional distress leads to worse outcomes in joint arthroplasty and spine surgery. However, there is limited data on the influence of impaired preoperative psychological function on foot and ankle outcomes. Modern tools like the Patient-Reported Outcomes Instrument Measurement System (PROMIS) can capture data such as emotional distress via the PROMIS anxiety domain. PROMIS anxiety queries symptoms of fearfulness, panic, and nervousness with scores strongly correlating to multiple legacy measures of anxiety. However, PROMIS anxiety as a surrogate for emotional distress has not been utilized in orthopedic research. We hypothesized that patients with greater preoperative emotional distress (i.e. higher PROMIS anxiety scores) would exhibit greater pain and less function than patients with lower anxiety following foot and ankle surgery. Methods: Elective foot and ankle surgeries from May 2016 – December 2016 were retrospectively identified. Patients with diabetes as well as those undergoing surgery for infection, trauma, or routine hardware removal were all excluded. PROMIS anxiety, pain interference (PI), physical function (PF), and depression scores were collected – data closest to surgery preoperatively and furthest from surgery postoperatively were used for analysis. Our study population was then grouped based on preoperative PROMIS anxiety, with scores greater than 60 indicating higher levels of emotional distress and scores below 60 indicating less impairment. A cutoff of PROMIS anxiety above 60 was selected as earlier studies have shown that threshold corresponds to clinically-significant amounts of anxiety based on traditional anxiety outcome measures. Additionally, PROMIS anxiety scores above 60 signify anxiety values one standard deviation or more away from the population average. Results: Patients with higher preoperative anxiety (average: 64.8, n=25) had greater preoperative pain and less function as compared to patients with less preoperative anxiety (average: 47.1, n=63) (PROMIS PI: 63.6 versus 59.1, P0.1) in PROMIS PI and PF following surgery (? PROMIS PI: 5.1 versus 7.3;? PROMIS PF: 1.5 versus 3.0; respectively) at equivalent follow-up (5.7 versus 6.3 months, respectively). However, postoperatively, patients with higher preoperative anxiety had more residual pain and greater functional disability as compared to patients with less preoperative emotional distress (PROMIS PI: 58.5 versus 51.8, P<0.001; PROMIS PF: 39.4 versus 44.7, P<0.001; respectively). Conclusion: Evidence of preoperative emotional distress – as assessed by the PROMIS anxiety instrument – predicted worse pain and function at early surgical follow-up. Detecting patients at-risk for poorer surgical outcomes remains a topic of interest in orthopedics. Our data suggest that the PROMIS anxiety tool could be useful in identifying such patients. It would be helpful, then, to counsel individuals with higher preoperative emotional distress that – despite significant improvements – residual pain and functional disability may persist after surgery. Continued surveillance will be necessary to determine if these between-group differences remain at longer-term follow-up

Outcomes following repeat ankle arthroscopy for osteochondral lesions of the talus (OLTs)

Category: Ankle, Arthroscopy Introduction/Purpose: Management of symptomatic osteochondral lesions of the talus (OLTs) previously treated with arthroscopy remains controversial. Many advocate for open surgical intervention, particularly in patients with larger OLTs. Minimal data, however, exists on the role for repeat ankle arthroscopy. Here, we describe our experience with repeat arthroscopy for symptomatic OLTs, hypothesizing similar pain and satisfaction scores regardless of OLT size. Methods: Our surgical database was queried to identify patients who underwent repeat arthroscopy from February, 1997 – May, 2015. From that cohort, we identified a subset of patients with a diagnosis of symptomatic OLT who were treated with arthroscopic debridement and microfracture. We then performed a retrospective chart review. Phone surveys were conducted to assess clinical outcomes including pain and satisfaction scores as well as to record any subsequent surgery reported by the patient. Using previously defined criteria for size threshold, OLTs were categorized as either small (=150 mm2) or large (> 150 mm2) based on operative dimensions noted at the time of repeat surgery. Results: We identified 15 patients who underwent repeat arthroscopy for symptomatic OLTs. Patients reported reasonable satisfaction (average: 7.3, SD: 2.7) but moderate residual pain (average: 4.6, SD: 3.3) at midterm follow-up (average: 5.0 years, SD: 2.8). Further surgery after repeat arthroscopy was performed in 20% (3/15) of patients. Only 1 patient developed a postoperative complication (superficial DVT treated with observation). Small (n=6) and large OLTs (n=9) had similar postoperative pain scores (4.2 ± 3.7 versus 4.9 ± 3.2), postoperative satisfaction levels (7.5 ± 3.4 versus 7.2 ± 2.3), and reoperation rates (33% versus 22%) (P>.05). Patients with larger OLTs were younger at the time of repeat arthroscopy (P=.026) with no differences in sex or BMI (P>.05) between groups. Conclusion: At midterm follow-up, repeat arthroscopy for symptomatic OLTs demonstrated reasonable satisfaction but with moderate residual pain and a 20% rate of subsequent surgery. There was no statistically significant difference in postoperative pain scores, satisfaction scores, or reoperation rates between small and large OLTs. Repeat arthroscopy for symptomatic OLTs can be done safely – however, patients should be educated to have guarded optimism regarding their outcome

Preoperative Emotional Distress Negatively Impacts Foot and Ankle Outcomes

Category: Outcomes Research Introduction/Purpose: Prior work has demonstrated that greater preoperative emotional distress leads to worse outcomes in joint arthroplasty and spine surgery. However, there is limited data on the influence of impaired preoperative psychological function on foot and ankle outcomes. Modern tools like the Patient-Reported Outcomes Instrument Measurement System (PROMIS) can capture data on emotional distress via the PROMIS anxiety domain. PROMIS anxiety queries symptoms of fearfulness, panic, and nervousness with scores strongly correlating to multiple legacy measures of anxiety. However, PROMIS anxiety as a surrogate for emotional distress has not been utilized in orthopedic research. Here, we hypothesized that patients with greater preoperative emotional distress (i.e. higher PROMIS anxiety scores) would exhibit greater pain and less function than patients with lower anxiety following foot and ankle surgery. Methods: Elective foot and ankle surgeries from May 2016 – December 2016 were retrospectively identified. Patients with diabetes as well as those undergoing surgery for infection, trauma, or routine hardware removal were all excluded. PROMIS anxiety, pain interference (PI), physical function (PF), and depression scores were collected – data closest to surgery preoperatively and furthest from surgery postoperatively were used for analysis. Our study population was then grouped based on preoperative PROMIS anxiety, with scores greater than 60 indicating higher levels of emotional distress and scores below 60 indicating less impairment. A cutoff of PROMIS anxiety above 60 was selected as earlier studies have shown that threshold corresponds to clinically-significant amounts of anxiety based on traditional anxiety outcome measures. Additionally, PROMIS anxiety scores above 60 signify anxiety values one standard deviation or more away from the population average. Results: Patients with higher preoperative anxiety (average: 64.8, n=25) had greater preoperative pain and less function compared to patients with less preoperative anxiety (average: 47.1, n=63) (PROMIS PI: 63.6 versus 59.1, P0.1) in PROMIS PI and PF following surgery (Delta PROMIS PI: 5.1 versus 7.3; Delta PROMIS PF: 1.5 versus 3.0) at equivalent follow-up (5.7 versus 6.3 months). However, postoperatively, patients with higher preoperative anxiety had more residual pain and greater functional disability compared to patients with less preoperative emotional distress (PROMIS PI: 58.5 versus 51.8, P<0.001; PROMIS PF: 39.4 versus 44.7, P<0.001). Conclusion: Evidence of preoperative emotional distress – as assessed by the PROMIS anxiety instrument – predicted worse pain and function at early surgical follow-up. Detecting patients at-risk for poorer surgical outcomes remains a topic of interest in orthopedics. Our data suggest that the PROMIS anxiety tool could be useful in identifying such patients. It would be helpful, then, to counsel individuals with higher preoperative emotional distress that – despite significant improvements – residual pain and functional disability may persist after surgery. Continued surveillance will be necessary to determine if these between-group differences remain at longer-term follow-up

The Arterial Anatomy of the Deltoid Ligament

Category: Ankle Introduction/Purpose: Injuries to the deltoid ligament complex on the medial aspect of the ankle account for 10-15% of ankle sprains. Chronic deltoid insufficiency can lead to medial or multidirectional ankle instability, necessitating operative stabilization. Many studies have examined the anatomy of the deltoid ligament complex, with a focus on characterizing the various bands that comprise its structure. To our knowledge the vascular supply to the deltoid ligament has not been previously studied. This information may have implications in the progression of deltoid injuries to chronic insufficiency, and is an important consideration when performing operative reconstruction of the deltoid ligament. The purpose of our study was to describe the vascular supply to the deltoid ligament utilizing a method of chemical debridement with cadaveric specimens. Methods: Twenty-seven matched pairs of adult cadaver legs, fifty-four legs total, were studied. Specimens with any signs of prior trauma or surgical treatment were excluded. The legs were amputated below the knee and injected with India Ink, followed by Ward Blue Latex, in the anterior tibial, posterior tibial and peroneal arteries. Specimens were chemically debrided utilizing 6.0% sodium hypochlorite, leaving vascular casts, ligaments and bones. The vascular supply to the deltoid ligament was evaluated, photographed, and recorded. Results: The vascular supply to the deltoid ligament complex was clearly visualized in 50 of the specimens. The deltoid ligament in all 50 specimens was supplied by arterial branches from the dorsalis pedis, specifically the medial tarsal arteries. Thirty-two of the specimens (64.0%) had an additional contribution from the anterior tibial artery, while the medial tarsal arteries were the only anterior vascular supply in the remaining eighteen specimens (36.0%). Thirty-nine specimens (78.0%) had additional arterial supply to the deltoid ligament from the posterior tibial artery. In thirteen (30.0%) of these specimens, the posterior tibial artery provided the dominant arterial supply, as determined by vessel diameter. Conclusion: Deltoid injuries can become chronic, leading to recurrent ankle instability. Our study shows that the deltoid ligament complex receives a consistent arterial supply from the dorsalis pedis and anterior tibial arteries, and that this anterior vasculature is the dominant supply in the majority of specimens. A large portion of our specimens also had additional arterial supply from the posterior tibial artery. Knowledge of the arterial anatomy of the deltoid ligament complex is valuable when planning operative treatment of medial ankle, and may also provide information for future studies examining the progression of medial ankle sprains to chronic deltoid insufficiency